Healthcare Provider Details

I. General information

NPI: 1669605085
Provider Name (Legal Business Name): COLLAN LEE KOEPPEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7825 FAY AVE. SUITE 249
LA JOLLA CA
92037
US

IV. Provider business mailing address

7825 FAY AVE. SUITE 249
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 858-736-4056
  • Fax:
Mailing address:
  • Phone: 858-736-4056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC31265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: