MEDICARE: TIM G. URSICH CHIROPRATIC, INC.

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	DC12564	CA

General Provider Information

NPI Number	:	1609922038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIM G. URSICH CHIROPRATIC, INC.

Provider Business Mailing Address
First Line	:	28633 S WESTERN AVE
Second Line	:	SUITE 200
City	:	RANCHO PALOS VERDES
State	:	CA
Zip	:	90275-0827
Country	:	US
Telephone Number	:	310-832-2622
Fax Number	:	310-832-2621

Provider Business Practice Location Address
First Line	:	28633 S WESTERN AVE
Second Line	:	SUITE 200
City	:	RANCHO PALOS VERDES
State	:	CA
Zip	:	90275-0827
Country	:	US
Telephone Number	:	310-832-2622
Fax Number	:	310-832-2621

Authorized Official
Title or Position	:	MEDICAL DIRECTOR-PRESIDENT
Name	:	DR. TIMOTHY G URSICH
Credential	:	D.C.
Telephone Number	:	310-832-2622

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	06/22/2021

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