Basic Information
| Provider Information | |||||||||
| NPI: | 1336150705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOCKWELL | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR DEPT 6008 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622821419 | ||||||||
| FaxNumber: | 5629204642 | ||||||||
| Practice Location | |||||||||
| Address1: | 2220 CLARK AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908152521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625974181 | ||||||||
| FaxNumber: | 5625977083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC17831 | CA | N | Chiropractic Providers | Chiropractor | 111N00000X | 17831 | CA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 350053321 | 01 | CA | RAILROAD MEDICARE | OTHER | DC0178310 | 05 | CA | MEDICAID | 00DC178310 | 01 | CA | BLUE SHIELD | OTHER |