Healthcare Provider Details

I. General information

NPI: 1144520040
Provider Name (Legal Business Name): JULIAN LANSING MINES IV D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 AVENIDA DEL MAR SUITE A
SAN CLEMENTE CA
92672-5540
US

IV. Provider business mailing address

4 CALLE CELESTIAL
SAN CLEMENTE CA
92673-6914
US

V. Phone/Fax

Practice location:
  • Phone: 949-436-2601
  • Fax: 949-498-4718
Mailing address:
  • Phone: 949-436-2601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC24513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: