Provider Demographics
NPI:1679566616
Name:MCEVILLY, BRIAN C (DC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:C
Last Name:MCEVILLY
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 1:2801 WATERMAN BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-2987
Mailing Address - Country:US
Mailing Address - Phone:707-427-1772
Mailing Address - Fax:707-427-1467
Practice Address - Street 1:2801 WATERMAN BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-2987
Practice Address - Country:US
Practice Address - Phone:707-427-1772
Practice Address - Fax:707-427-1467
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 22239111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0222390Medicare PIN