Provider Demographics
NPI:1730258989
Name:KINNEAR, CLINTON LANE (DC)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:LANE
Last Name:KINNEAR
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:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7176
Mailing Address - Country:US
Mailing Address - Phone:760-908-9053
Mailing Address - Fax:760-729-3201
Practice Address - Street 1:785 GRAND AVE
Practice Address - Street 2:#100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2370
Practice Address - Country:US
Practice Address - Phone:760-729-3200
Practice Address - Fax:760-729-3201
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104002014111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350001097Medicare ID - Type Unspecified