Healthcare Provider Details

I. General information

NPI: 1629500772
Provider Name (Legal Business Name): BORIS CICAK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 UNIVERSITY AV
SAN DIEGO CA
92103
US

IV. Provider business mailing address

1452 UNIVERSITY AVE
SAN DIEGO CA
92103-3405
US

V. Phone/Fax

Practice location:
  • Phone: 619-291-5433
  • Fax:
Mailing address:
  • Phone: 619-291-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number33818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: