Provider Demographics
NPI:1083795074
Name:GROSS, LONNIE SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:SCOTT
Last Name:GROSS
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 1:10526 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4614
Mailing Address - Country:US
Mailing Address - Phone:718-444-9007
Mailing Address - Fax:718-531-5322
Practice Address - Street 1:10526 AVENUE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4614
Practice Address - Country:US
Practice Address - Phone:718-444-9007
Practice Address - Fax:718-531-5322
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006491111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX46341Medicare ID - Type UnspecifiedMEDICARE
NY18144Medicare UPIN