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General NPI Number Information
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NPI Number | 1790294783
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Entity Type | Organization
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Legal Business Name | D'ANTONIO CHIROPRACTIC CLINIC LLC
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 10 CRATER LAKE AVE
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City | MEDFORD
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State | OR
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Zip | 97504-7445
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Country | US
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Telephone | 541-608-0169
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Fax |
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Provider Business Mailing Address
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Address Line | 10 CRATER LAKE AVE
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City | MEDFORD
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State | OR
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Zip | 97504-7445
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Country | US
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Telephone | 541-608-0169
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Fax |
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Authorized Official
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Title or Position | EMPLOYEE
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Name | DEIRDRE D'ANTONIO
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Credential | DC
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Telephone | 541-608-0169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2576
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License Number State | OR
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