Provider Demographics
NPI:1003831884
Name:ANDERSON, GREGG CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:CHARLES
Last Name:ANDERSON
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 1:3517 MARCONI AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5328
Mailing Address - Country:US
Mailing Address - Phone:916-485-5433
Mailing Address - Fax:916-485-2857
Practice Address - Street 1:3517 MARCONI AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5328
Practice Address - Country:US
Practice Address - Phone:916-485-5433
Practice Address - Fax:916-485-2857
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-24270111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0242700Medicare ID - Type UnspecifiedMEDICARE