MEDICARE: RUSUDAN DEDIASHVILI CHIROPRACTIC CORP.

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	DC0255610	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770756892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSUDAN DEDIASHVILI CHIROPRACTIC CORP.

Provider Business Mailing Address
First Line	:	13760 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-2324
Country	:	US
Telephone Number	:	818-922-7713
Fax Number	:	323-965-1411

Provider Business Practice Location Address
First Line	:	13760 VICTORY BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91401-2324
Country	:	US
Telephone Number	:	818-922-7713
Fax Number	:	323-965-1411

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RUSUDAN DEDIASHVILI
Credential	:	D.C.
Telephone Number	:	818-922-7713

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	05/28/2020

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