Provider Demographics
NPI:1942420377
Name:MUCCILLO, RICHARD P (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
Last Name:MUCCILLO
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 1:800 GRAND AVE
Mailing Address - Street 2:B-4
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1808
Mailing Address - Country:US
Mailing Address - Phone:760-729-0047
Mailing Address - Fax:760-729-0915
Practice Address - Street 1:800 GRAND AVE
Practice Address - Street 2:B-4
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1808
Practice Address - Country:US
Practice Address - Phone:760-729-0047
Practice Address - Fax:760-729-0915
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15102111NN0400X
HIDC322111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT83234Medicare UPIN