=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497574487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN JESUS VILLA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2024
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 E 14TH ST
-----------------------------------------------------
City | HEBER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-457-8727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 125
-----------------------------------------------------
City | HEBER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92249-0125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-457-8727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 34106
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------