Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | DC28729 | CA |
N | 111NR0400X | Rehabilitation Chiropractor | DC28729 | CA |
NPI | 1003087156 |
---|---|
Provider Name | Dr. Edward Reza JR. |
First Address | Orange, CA 92866-1429 |
Second Address | Newport Beach, CA 92660-1924 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2008 |
Last Update Date | 08/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC28729 | CHIROPRACTIC LICENSE (01) | CA |