=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538244769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKWELDER CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24721 LA PLZ
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92629-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-240-2546
-----------------------------------------------------
Fax | 949-240-3804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25762 VIA DEL REY
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-240-0483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ OWNER
-----------------------------------------------------
Name | DR. CLYDE SPENCER BLACKWELDER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 949-240-2546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC23746
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------