Provider Demographics
NPI:1104849793
Name:GRANNIS, GORDON HARRIMAN (DC)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:HARRIMAN
Last Name:GRANNIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:GORDON
Other - Middle Name:H
Other - Last Name:GRANNIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:24541 PACIFIC PARK DR STE 290
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3058
Mailing Address - Country:US
Mailing Address - Phone:949-448-8599
Mailing Address - Fax:949-448-8595
Practice Address - Street 1:24541 PACIFIC PARK DR STE 290
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3058
Practice Address - Country:US
Practice Address - Phone:949-448-8599
Practice Address - Fax:949-448-8595
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17427Medicare UPIN