Provider Demographics
NPI:1457454233
Name:MCKILLICAN, ERIC JON (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:MCKILLICAN
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 1:13405 FOLSOM BLVD STE 505
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-4739
Mailing Address - Country:US
Mailing Address - Phone:916-353-1800
Mailing Address - Fax:916-353-1802
Practice Address - Street 1:13405 FOLSOM BLVD STE 505
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4739
Practice Address - Country:US
Practice Address - Phone:916-353-1800
Practice Address - Fax:916-353-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0233200OtherBLUE SHIELD
CAU59361Medicare UPIN