=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699830620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAN DEUSEN CHIROPRACTIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 ADAMS AVE STE 306
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-556-6966
-----------------------------------------------------
Fax | 714-242-1925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 ADAMS AVE STE 306
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-556-6966
-----------------------------------------------------
Fax | 714-242-1925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER
-----------------------------------------------------
Name | LESLIE VAN DEUSEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 949-584-9888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC28754
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------