Healthcare Provider Details

I. General information

NPI: 1740407758
Provider Name (Legal Business Name): TIMOTHY GLENCROSS SWIFT DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 CAMINO MIRA COSTA SUITE A
SAN CLEMENTE CA
92672
US

IV. Provider business mailing address

3551 CAMINO MIRA COSTA SUITE A
SAN CLEMENTE CA
92672
US

V. Phone/Fax

Practice location:
  • Phone: 949-751-4000
  • Fax: 949-751-4004
Mailing address:
  • Phone: 949-751-4000
  • Fax: 949-751-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC27543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: