=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649436486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LLANTADA CHIROPRACTIC A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2008
-----------------------------------------------------
Last Update Date | 04/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5252 BALBOA AVE STE 701
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-6930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-384-6556
-----------------------------------------------------
Fax | 858-225-8320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5252 BALBOA AVE STE 701
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-6930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-384-6556
-----------------------------------------------------
Fax | 858-225-8320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | RUMEL MENDOZA LLANTADA
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 858-384-6556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | COR2360
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------