Provider Demographics
NPI:1477797579
Name:KANCILIA, DIRK H (DC)
Entity Type:Individual
Prefix:DR
First Name:DIRK
Middle Name:H
Last Name:KANCILIA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:33175 TEMECULA PKWY
Mailing Address - Street 2:A125
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-7300
Mailing Address - Country:US
Mailing Address - Phone:858-345-4114
Mailing Address - Fax:866-920-8576
Practice Address - Street 1:16980 VIA TAZON
Practice Address - Street 2:160
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1633
Practice Address - Country:US
Practice Address - Phone:858-345-4114
Practice Address - Fax:858-679-8411
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CADC16440111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor