=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881991750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARCIA & KAMBOURAKIS CHIROPRACTIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2011
-----------------------------------------------------
Last Update Date | 03/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 AGATE AVE STE C
-----------------------------------------------------
City | BALBOA ISLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92662-1085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-723-0702
-----------------------------------------------------
Fax | 949-723-0026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 AGATE AVE STE C
-----------------------------------------------------
City | BALBOA ISLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92662-1085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-723-0702
-----------------------------------------------------
Fax | 949-723-0026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CHIROPRACTOR
-----------------------------------------------------
Name | DR. DANIEL THOMAS GARCIA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 949-723-0702
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-28103
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT-5678
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-31351
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------