Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | DC19718 | CA |
NPI | 1063598076 |
---|---|
Provider Name | Mrs. Michell Irvine |
First Address | Redondo Beach, CA 90277 |
Second Address | Redondo Beach, CA 90277-3042 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC19718 | (02) | CA |