Healthcare Provider Details

I. General information

NPI: 1740479625
Provider Name (Legal Business Name): M E HALOUZKA DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12348 CREEKVIEW DRIVE
SAN DIEGO CA
92128
US

IV. Provider business mailing address

12348 CREEKVIEW DRIVE
SAN DIEGO CA
92128
US

V. Phone/Fax

Practice location:
  • Phone: 858-391-0434
  • Fax:
Mailing address:
  • Phone: 858-391-0434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number20615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number20615DC
License Number StateCA

VIII. Authorized Official

Name: MS. MARY ELIZABETH HALOUZKA
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 858-391-0434