Healthcare Provider Details

I. General information

NPI: 1861928145
Provider Name (Legal Business Name): JUSTIN WILCOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 G ST
SAN DIEGO CA
92101
US

IV. Provider business mailing address

1050 ISLAND AVE UNIT 309
SAN DIEGO CA
92101-7260
US

V. Phone/Fax

Practice location:
  • Phone: 619-786-5997
  • Fax:
Mailing address:
  • Phone: 813-469-0409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHR.0007606
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberEL.2786658
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: