=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750984068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW RYAN UPCHURCH DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 11/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8950 VILLA LA JOLLA DR STE B212
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-588-3111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2893 MCGRAW ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-6044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-381-3759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 34941
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------