Provider Demographics
NPI:1538244769
Name:BLACKWELDER CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:BLACKWELDER CHIROPRACTIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-240-2546
Mailing Address - Street 1:25762 VIA DEL REY
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4444
Mailing Address - Country:US
Mailing Address - Phone:949-240-0483
Mailing Address - Fax:
Practice Address - Street 1:24721 LA PLZ
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2509
Practice Address - Country:US
Practice Address - Phone:949-240-2546
Practice Address - Fax:949-240-3804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23746111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSOCIAL SECURITY NUMBER