Basic Information
| Provider Information | |||||||||
| NPI: | 1083647051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACEBO | ||||||||
| FirstName: | ANDRE | ||||||||
| MiddleName: | MARCEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 POSADA LN | ||||||||
| Address2: | SUITE A-C | ||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934654003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055426700 | ||||||||
| FaxNumber: | 8055426791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NS0005X | DC 20074 | CA | Y | Chiropractic Providers | Chiropractor | Sports Physician |
ID Information
| ID | Type | State | Issuer | Description | W1508A | 01 | CA | CHCCC, TEMPLETON MEDICARE GROUP # | OTHER | FHC70936F | 01 | CA | TEMPLETON M/CAL # | OTHER | W1508 | 01 | CA | MEDICARE GROUP NUMBER | OTHER |