Healthcare Provider Details

I. General information

NPI: 1578013371
Provider Name (Legal Business Name): CODY JAMES MCKILLIP DC, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 07/01/2023
Certification Date: 07/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-1001 KAIMALIE ST # 106
EWA BEACH HI
96706-6247
US

IV. Provider business mailing address

91-1011 KAIPALAOA ST APT 404
EWA BEACH HI
96706-6117
US

V. Phone/Fax

Practice location:
  • Phone: 808-637-2608
  • Fax:
Mailing address:
  • Phone: 309-737-9553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-1574-0
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: