Provider Demographics
NPI:1144529223
Name:BANTIQUE CHIROPRACTIC, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BANTIQUE CHIROPRACTIC, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMELO
Authorized Official - Middle Name:DICHOSA
Authorized Official - Last Name:BANTIQUE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:916-483-3423
Mailing Address - Street 1:3301 WATT AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-3621
Mailing Address - Country:US
Mailing Address - Phone:916-483-3423
Mailing Address - Fax:
Practice Address - Street 1:3301 WATT AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-3621
Practice Address - Country:US
Practice Address - Phone:916-483-3423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29892111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0298920Medicare UPIN