Provider Demographics
NPI:1548668528
Name:KINETIC WELLNESS CENTER. DR. GEORGE CHIROPRACTIC CORP
Entity type:Organization
Organization Name:KINETIC WELLNESS CENTER. DR. GEORGE CHIROPRACTIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO/MANAGING W-2 EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-799-2366
Mailing Address - Street 1:6940 SANTA TERESA BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1345
Mailing Address - Country:US
Mailing Address - Phone:408-429-2888
Mailing Address - Fax:405-622-4251
Practice Address - Street 1:6940 SANTA TERESA BLVD STE 6
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1345
Practice Address - Country:US
Practice Address - Phone:408-429-2888
Practice Address - Fax:405-622-4251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0226780Medicare PIN