Provider Demographics
NPI:1093802449
Name:GENTRY, STEVEN (DC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:GENTRY
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 80357
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-0357
Mailing Address - Country:US
Mailing Address - Phone:949-888-0404
Mailing Address - Fax:949-888-0818
Practice Address - Street 1:22331 EL PASEO
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2822
Practice Address - Country:US
Practice Address - Phone:949-888-0404
Practice Address - Fax:949-888-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZAT174OtherBLUE SHIELD
CAU90924Medicare UPIN
CAZAT174OtherBLUE SHIELD