Basic Information
| Provider Information | |||||||||
| NPI: | 1205128949 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDEAL SPINE & REHAB | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17251 17TH ST STE A&B | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927801970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148322273 | ||||||||
| FaxNumber: | 7148322272 | ||||||||
| Practice Location | |||||||||
| Address1: | 17251 17TH ST STE A&B | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927801970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148322273 | ||||||||
| FaxNumber: | 7148322272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2011 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PACELLI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7148322273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.C. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC30257 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 111N00000X | DC11750 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.