Provider Demographics
NPI:1114070950
Name:GREATHOUSE, WAYNE (DC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:GREATHOUSE
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 1:130 AVENIDA CABRILLO
Mailing Address - Street 2:STE C
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5509
Mailing Address - Country:US
Mailing Address - Phone:949-481-8282
Mailing Address - Fax:949-218-6303
Practice Address - Street 1:130 AVENIDA CABRILLO
Practice Address - Street 2:STE C
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5509
Practice Address - Country:US
Practice Address - Phone:949-481-8282
Practice Address - Fax:949-218-6303
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28049111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV47495Medicare UPIN
CADC22352Medicare ID - Type UnspecifiedMEDICARE