Provider Demographics
NPI:1043496441
Name:DISIENA FAMILY CHIROPRACTIC, A PROF CORP
Entity type:Organization
Organization Name:DISIENA FAMILY CHIROPRACTIC, A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DISIENA
Authorized Official - Suffix:
Authorized Official - Credentials:DC, FICA, QME
Authorized Official - Phone:949-559-6030
Mailing Address - Street 1:6 VENTURE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3340
Mailing Address - Country:US
Mailing Address - Phone:949-559-6030
Mailing Address - Fax:949-559-6037
Practice Address - Street 1:6 VENTURE
Practice Address - Street 2:SUITE 115
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-8853
Practice Address - Country:US
Practice Address - Phone:949-559-6030
Practice Address - Fax:949-559-6037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17101111N00000X
CADC17166111N00000X
CADC25546111N00000X
CADC26991111N00000X
CADC25305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU74346Medicare UPIN
CABB646AMedicare PIN
CABM748ZMedicare PIN
CAU57880Medicare UPIN
CABB646ZMedicare PIN
CABF569ZMedicare PIN
CABD992ZMedicare PIN
CAU69643Medicare UPIN
CAU48637Medicare UPIN