Provider Demographics
NPI:1245345925
Name:IVERSEN, STEPHEN DALE (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DALE
Last Name:IVERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E KATELLA AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-5248
Mailing Address - Country:US
Mailing Address - Phone:714-633-2225
Mailing Address - Fax:714-532-2514
Practice Address - Street 1:2901 E KATELLA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5248
Practice Address - Country:US
Practice Address - Phone:714-633-2225
Practice Address - Fax:714-532-2514
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19846111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC019846Medicare UPIN