Healthcare Provider Details

I. General information

NPI: 1952584971
Provider Name (Legal Business Name): ILYA MISCHA SKOLNIKOFF D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 C ST SUITE 9
SAN RAFAEL CA
94901-3857
US

IV. Provider business mailing address

710 C ST SUITE 9
SAN RAFAEL CA
94901-3857
US

V. Phone/Fax

Practice location:
  • Phone: 415-459-4313
  • Fax: 419-715-9257
Mailing address:
  • Phone: 415-459-4313
  • Fax: 419-715-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC30524
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: