Provider Demographics
NPI:1104822139
Name:DE GRUCHY, SUSAN JENNIFER (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JENNIFER
Last Name:DE GRUCHY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5745 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-6203
Mailing Address - Country:US
Mailing Address - Phone:559-431-4838
Mailing Address - Fax:559-431-4841
Practice Address - Street 1:5745 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6203
Practice Address - Country:US
Practice Address - Phone:559-431-4838
Practice Address - Fax:559-431-4841
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 22641111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU45089Medicare UPIN