Provider Demographics
NPI:1437262276
Name:CANYON LAKES CHIROPRACTIC GROUP
Entity type:Organization
Organization Name:CANYON LAKES CHIROPRACTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:925-735-8508
Mailing Address - Street 1:500 BOLLINGER CANYON WAY STE 15A
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5252
Mailing Address - Country:US
Mailing Address - Phone:925-735-8508
Mailing Address - Fax:925-735-2374
Practice Address - Street 1:500 BOLLINGER CANYON WAY STE 15A
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-5252
Practice Address - Country:US
Practice Address - Phone:925-735-8508
Practice Address - Fax:925-735-2374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-23525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0235250Medicare ID - Type Unspecified