Provider Demographics
NPI:1205890712
Name:MOLINA CHIROPRACTIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MOLINA CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-248-2826
Mailing Address - Street 1:647 CAMINO DE LOS MARES
Mailing Address - Street 2:226 POST STOP108-90
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2825
Mailing Address - Country:US
Mailing Address - Phone:949-248-2826
Mailing Address - Fax:949-248-2815
Practice Address - Street 1:647 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 226
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2825
Practice Address - Country:US
Practice Address - Phone:949-248-2826
Practice Address - Fax:949-248-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07388ZOtherBLUE CROSS/BLUE SHIELD
CAU58912Medicare UPIN
CAED053AMedicare PIN