Healthcare Provider Details

I. General information

NPI: 1508294844
Provider Name (Legal Business Name): JOSEPH IACCINO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 FREMONT ST
COLUSA CA
95932-2534
US

IV. Provider business mailing address

223 N 6TH ST STE 40
BOISE ID
83702-6092
US

V. Phone/Fax

Practice location:
  • Phone: 530-458-8635
  • Fax: 530-458-7830
Mailing address:
  • Phone: 661-674-7854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIA-1537
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number32571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: