MEDICARE: VITALITY FAMILY 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	111N00000X	Chiropractor	32830	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB223013	OTHER	CA	MEDICARE ID

General Provider Information

NPI Number	:	1255711917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY FAMILY CHIROPRACTIC

Provider Business Mailing Address
First Line	:	99 LONG CT
Second Line	:	#103
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-6066
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	99 LONG CT
Second Line	:	#103
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-6066
Country	:	US
Telephone Number	:	805-379-3653
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRADY CHRISTOPHER SALCIDO
Credential	:	D.C.
Telephone Number	:	805-379-3653

Provider Enumeration Date	:	06/08/2015
Last Update Date	:	06/08/2015

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