Healthcare Provider Details

I. General information

NPI: 1194956102
Provider Name (Legal Business Name): MIKE SCOTT WASILISIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MIKE SCOTT WASILISIN D.C.

II. Dates (important events)

Enumeration Date: 08/07/2009
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W C ST
SAN DIEGO CA
92101-3533
US

IV. Provider business mailing address

6215 EL CAMINO REAL SUITE 100
CARLSBAD CA
92009-1604
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-4030
  • Fax: 619-232-4255
Mailing address:
  • Phone: 760-603-7900
  • Fax: 760-603-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number31327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: