Basic Information
Provider Information
NPI: 1003010638
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: AUSTIN
FirstName: BRIAN
MiddleName: CONANT
NamePrefix: DR.
NameSuffix:  
Credential: D.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4861 CONVOY ST
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921111610
CountryCode: US
TelephoneNumber: 6192994847
FaxNumber: 6192994837
Practice Location
Address1: 4861 CONVOY ST
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921111610
CountryCode: US
TelephoneNumber: 6192994847
FaxNumber: 6192994837
Other Information
ProviderEnumerationDate: 06/14/2007
LastUpdateDate: 06/13/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000XDC27717CAY Chiropractic ProvidersChiropractor 

No ID Information.


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