Provider Demographics
NPI:1053748533
Name:COSTA CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:COSTA CHIROPRACTIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRATOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JAYNE ELIZABETH
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-637-1668
Mailing Address - Street 1:181 AVENIDA VAQUERO
Mailing Address - Street 2:STE D
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3600
Mailing Address - Country:US
Mailing Address - Phone:949-218-4750
Mailing Address - Fax:949-276-7393
Practice Address - Street 1:181 AVENIDA VAQUERO
Practice Address - Street 2:STE D
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3600
Practice Address - Country:US
Practice Address - Phone:949-218-4750
Practice Address - Fax:949-276-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29364111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB260351Medicare PIN