Provider Demographics
NPI:1861177016
Name:AZUA, DESIRAE MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:DESIRAE
Middle Name:MARIE
Last Name:AZUA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W KETTLEMAN LN STE 104
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4334
Mailing Address - Country:US
Mailing Address - Phone:209-334-6947
Mailing Address - Fax:209-334-6969
Practice Address - Street 1:2000 W KETTLEMAN LN STE 104
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4334
Practice Address - Country:US
Practice Address - Phone:209-334-6947
Practice Address - Fax:209-334-6969
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor