Provider Demographics
NPI:1083624795
Name:GUTIERREZ, MARIO SKILES (DC)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:SKILES
Last Name:GUTIERREZ
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 1549
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-1549
Mailing Address - Country:US
Mailing Address - Phone:916-853-2002
Mailing Address - Fax:916-853-2009
Practice Address - Street 1:2286 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4342
Practice Address - Country:US
Practice Address - Phone:916-853-2002
Practice Address - Fax:916-853-2009
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC029780Medicare ID - Type Unspecified
CAV05302Medicare UPIN