Healthcare Provider Details

I. General information

NPI: 1497574487
Provider Name (Legal Business Name): JUAN JESUS VILLA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 E 14TH ST
HEBER CA
92249
US

IV. Provider business mailing address

PO BOX 125
HEBER CA
92249-0125
US

V. Phone/Fax

Practice location:
  • Phone: 760-457-8727
  • Fax:
Mailing address:
  • Phone: 760-457-8727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number34106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: