Provider Demographics
NPI:1457828618
Name:WILCOX BAYSIDE SPINE & SPORT CHIROPRACTIC
Entity Type:Organization
Organization Name:WILCOX BAYSIDE SPINE & SPORT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-469-0409
Mailing Address - Street 1:838 G ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6421
Mailing Address - Country:US
Mailing Address - Phone:619-786-5997
Mailing Address - Fax:
Practice Address - Street 1:838 G ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6421
Practice Address - Country:US
Practice Address - Phone:619-786-5997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty