Provider Demographics
NPI:1225060536
Name:HOLMBERG, GREGORY LEE (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:HOLMBERG
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 1:4709 EAGLES LANDING ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-5506
Mailing Address - Country:US
Mailing Address - Phone:316-734-9049
Mailing Address - Fax:
Practice Address - Street 1:8620 E 32ND CT N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4007
Practice Address - Country:US
Practice Address - Phone:316-612-0600
Practice Address - Fax:316-612-1140
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0104872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00229176OtherMEDICARE RAILRD.
KS062055OtherBLUE CROSS BLUE SHIELD
KS062055OtherBLUE CROSS BLUE SHIELD