Provider Demographics
NPI:1730251596
Name:DESROCHES, MARY KIMBERLY (DC, BPE)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KIMBERLY
Last Name:DESROCHES
Suffix:
Gender:F
Credentials:DC, BPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12117 RAMSEY DR
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-4039
Mailing Address - Country:US
Mailing Address - Phone:562-392-0627
Mailing Address - Fax:
Practice Address - Street 1:7217 PAINTER AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1451
Practice Address - Country:US
Practice Address - Phone:562-392-0627
Practice Address - Fax:562-324-6846
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28306111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28306Medicare UPIN
CADC28306Medicare ID - Type UnspecifiedCHIROPRACTOR