Provider Demographics
NPI:1437265477
Name:CALVILLO, SIMON PAUL (DC)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:PAUL
Last Name:CALVILLO
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 1:1322 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-2555
Mailing Address - Country:US
Mailing Address - Phone:828-289-6828
Mailing Address - Fax:
Practice Address - Street 1:1322 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-2555
Practice Address - Country:US
Practice Address - Phone:828-245-4002
Practice Address - Fax:828-245-4025
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2198111N00000X
CO4234111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890829FMedicaid
NC0829FOtherBLUE CROSS BLUE SHIELD
NC262694OtherMAMSI
NC14163723OtherWASAU
NC890829FMedicaid
NC2333339Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NC2450315AMedicare ID - Type UnspecifiedINDIVIDUAL