Provider Demographics
NPI:1861533069
Name:CHIROPRACTIC WELLNESS CLINIC
Entity type:Organization
Organization Name:CHIROPRACTIC WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-945-7717
Mailing Address - Street 1:615 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-8521
Mailing Address - Country:US
Mailing Address - Phone:408-945-7717
Mailing Address - Fax:408-946-8145
Practice Address - Street 1:615 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-8521
Practice Address - Country:US
Practice Address - Phone:408-945-7717
Practice Address - Fax:408-946-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28600ZMedicare ID - Type UnspecifiedGROUP ID