Provider Demographics
NPI:1043497043
Name:GREENLEE, GARY LYNN JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
Last Name:GREENLEE
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 HEALTH WAY DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1434
Mailing Address - Country:US
Mailing Address - Phone:573-438-8500
Mailing Address - Fax:573-438-8787
Practice Address - Street 1:108 FRIZZELL ST
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1505
Practice Address - Country:US
Practice Address - Phone:573-438-8500
Practice Address - Fax:573-438-8787
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003017111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO255780001Medicare PIN