Provider Demographics
NPI:1114087517
Name:HENDERSON, C. GREG (DC)
Entity Type:Individual
Prefix:DR
First Name:C.
Middle Name:GREG
Last Name:HENDERSON
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 1:5256 S MISSION RD
Mailing Address - Street 2:#406
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-3614
Mailing Address - Country:US
Mailing Address - Phone:760-728-2800
Mailing Address - Fax:760-509-1313
Practice Address - Street 1:5256 S MISSION RD
Practice Address - Street 2:#406
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3614
Practice Address - Country:US
Practice Address - Phone:760-728-2800
Practice Address - Fax:760-509-1313
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT05058Medicare UPIN
CAWDC13548AMedicare ID - Type Unspecified