Provider Demographics
NPI:1033214523
Name:WOODWARD, GARY (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WOODWARD
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 1:2175 FOOTHILL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2958
Mailing Address - Country:US
Mailing Address - Phone:909-593-2566
Mailing Address - Fax:909-593-6809
Practice Address - Street 1:2175 FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2958
Practice Address - Country:US
Practice Address - Phone:909-593-2566
Practice Address - Fax:909-593-6809
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT06603Medicare UPIN
CADC17963Medicare PIN