Healthcare Provider Details

I. General information

NPI: 1023167434
Provider Name (Legal Business Name): JEROME MICHAEL DECAPUA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39032 HIGHWAY 299 SUITE 4
WILLOW CREEK CA
95573-0540
US

IV. Provider business mailing address

PO BOX 540
WILLOW CREEK CA
95573-0540
US

V. Phone/Fax

Practice location:
  • Phone: 530-629-2474
  • Fax:
Mailing address:
  • Phone: 530-629-2474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15178
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: