Provider Demographics
NPI:1033238365
Name:DE FOREST, GARY (DC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:DE FOREST
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 1:2304 SAN DIEGO AVE STE C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2896
Mailing Address - Country:US
Mailing Address - Phone:619-291-2462
Mailing Address - Fax:619-291-9242
Practice Address - Street 1:2304 SAN DIEGO AVE STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2896
Practice Address - Country:US
Practice Address - Phone:619-291-2462
Practice Address - Fax:619-291-9242
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD.C. 16331111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor