1396978078 NPI number — ADAM MCKILLICAN CHIROPRACTIC INC

Table of content: (NPI 1396978078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396978078 NPI number — ADAM MCKILLICAN CHIROPRACTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADAM MCKILLICAN CHIROPRACTIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396978078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15550 ROCKFIELD BLVD
Provider Second Line Business Mailing Address:
B220
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-598-9999
Provider Business Mailing Address Fax Number:
949-598-9990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1437 S VICTORIA AVE
Provider Second Line Business Practice Location Address:
F
Provider Business Practice Location Address City Name:
VENTURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93003-6549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-233-6970
Provider Business Practice Location Address Fax Number:
805-676-1142
Provider Enumeration Date:
08/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MCKILLICAN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
805-233-6970

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC25899 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC25899 . This is a "CHIROPRACTIC LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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