Provider Demographics
NPI:1285633826
Name:KILCUP, DARRELL R (DC)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:R
Last Name:KILCUP
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7016 N 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-8402
Mailing Address - Country:US
Mailing Address - Phone:602-864-0304
Mailing Address - Fax:602-864-0990
Practice Address - Street 1:7016 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8402
Practice Address - Country:US
Practice Address - Phone:602-864-0304
Practice Address - Fax:602-864-0990
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4935111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0930450OtherBCBS PIN #
AZAZ0930450OtherBCBS PIN #