=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477797579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIRK H KANCILIA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2009
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16980 VIA TAZON 160
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92127-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-345-4114
-----------------------------------------------------
Fax | 858-679-8411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33175 TEMECULA PKWY A125
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92592-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-345-4114
-----------------------------------------------------
Fax | 866-920-8576
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC16440
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------