Provider Demographics
NPI:1528361359
Name:ILLIA, GINA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:ILLIA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 GRAND AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2370
Mailing Address - Country:US
Mailing Address - Phone:760-729-3200
Mailing Address - Fax:
Practice Address - Street 1:785 GRAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2370
Practice Address - Country:US
Practice Address - Phone:760-729-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor