Provider Demographics
NPI:1811016116
Name:BOELK, CASSIDY JAMES (DC)
Entity Type:Individual
Prefix:MR
First Name:CASSIDY
Middle Name:JAMES
Last Name:BOELK
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 1:1764 SAN DIEGO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1987
Mailing Address - Country:US
Mailing Address - Phone:619-298-0800
Mailing Address - Fax:619-298-8080
Practice Address - Street 1:1764 SAN DIEGO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-1987
Practice Address - Country:US
Practice Address - Phone:619-298-0800
Practice Address - Fax:619-298-8080
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor