Provider Demographics
NPI:1225118177
Name:GROOTENDORST, DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GROOTENDORST
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 1:900 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-4555
Mailing Address - Country:US
Mailing Address - Phone:559-674-8892
Mailing Address - Fax:
Practice Address - Street 1:900 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-4555
Practice Address - Country:US
Practice Address - Phone:559-674-8892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000470Medicaid
CAGDC000470Medicaid
CAT88802Medicare UPIN