Provider Demographics
NPI:1194956102
Name:WASILISIN, MIKE SCOTT (DC)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:SCOTT
Last Name:WASILISIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:SCOTT
Other - Last Name:WASILISIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:6215 EL CAMINO REAL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-1604
Mailing Address - Country:US
Mailing Address - Phone:760-603-7900
Mailing Address - Fax:760-603-7997
Practice Address - Street 1:444 W C ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3533
Practice Address - Country:US
Practice Address - Phone:619-232-4030
Practice Address - Fax:619-232-4255
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31327111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation