MEDICARE: DR. LEO VIC SEBBAS D.C.

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	DC 10960	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC 10960	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1477662146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEO VIC SEBBAS D.C.

Provider Business Mailing Address
First Line	:	9480 BASELINE RD
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-5822
Country	:	US
Telephone Number	:	909-980-1400
Fax Number	:	909-987-5258

Provider Business Practice Location Address
First Line	:	9480 BASELINE RD
Second Line	:
City	:	ALTA LOMA
State	:	CA
Zip	:	91701-5822
Country	:	US
Telephone Number	:	909-980-1400
Fax Number	:	909-987-5258

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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