Provider Demographics
NPI:1053590794
Name:URSICH, TIM G (DC)
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:G
Last Name:URSICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28633 S WESTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0817
Mailing Address - Country:US
Mailing Address - Phone:310-832-2622
Mailing Address - Fax:310-832-2621
Practice Address - Street 1:28633 S WESTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0817
Practice Address - Country:US
Practice Address - Phone:310-832-2622
Practice Address - Fax:310-832-2621
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12564111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC12564Medicare PIN