Healthcare Provider Details

I. General information

NPI: 1700177540
Provider Name (Legal Business Name): MIKE KUOPPAMAKI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3784 CLAIREMONT DR
SAN DIEGO CA
92117-5916
US

IV. Provider business mailing address

3784 CLAIREMONT DR
SAN DIEGO CA
92117-5916
US

V. Phone/Fax

Practice location:
  • Phone: 858-272-0074
  • Fax: 858-272-7574
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 31108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: