Provider Demographics
NPI:1710005541
Name:BODZIN CHIROPRACTIC PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BODZIN CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:I
Authorized Official - Last Name:BODZIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:858-541-0505
Mailing Address - Street 1:6030 SANTO RD
Mailing Address - Street 2:D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-1196
Mailing Address - Country:US
Mailing Address - Phone:858-541-0505
Mailing Address - Fax:858-541-0527
Practice Address - Street 1:6030 SANTO RD
Practice Address - Street 2:D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-1196
Practice Address - Country:US
Practice Address - Phone:858-541-0505
Practice Address - Fax:858-541-0527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29627111N00000X
CADC23213111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19087Medicare ID - Type UnspecifiedGROUP NUMBER