Provider Demographics
NPI:1114957602
Name:STINE, GABRIEL L (DC)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:L
Last Name:STINE
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 1:17330 BEAR VALLEY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-245-8182
Mailing Address - Fax:760-245-2123
Practice Address - Street 1:17330 BEAR VALLEY RD
Practice Address - Street 2:STE 105
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-245-8182
Practice Address - Fax:760-245-2123
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0215230Medicare ID - Type Unspecified
U44701Medicare UPIN