MEDICARE: PHILIPS SAN PEDRO CHIROPRACTIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	268581	CA

General Provider Information

NPI Number	:	1093249914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILIPS SAN PEDRO CHIROPRACTIC

Provider Business Mailing Address
First Line	:	505 SOUTH PACIFIC AVENUE
Second Line	:	SUITE 104
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2682
Country	:	US
Telephone Number	:	310-935-2935
Fax Number	:	310-751-7002

Provider Business Practice Location Address
First Line	:	505 SOUTH PACIFIC AVENUE
Second Line	:	SUITE 104
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2682
Country	:	US
Telephone Number	:	310-935-2935
Fax Number	:	310-751-7002

Authorized Official
Title or Position	:	CEO
Name	:	DR. RAYMOND JOE PHILIS
Credential	:	D.C.
Telephone Number	:	310-935-2935

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	04/18/2017

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