Provider Demographics
NPI:1235241944
Name:GORDON H GRANNIS, D.C., A CHIROPRACTIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GORDON H GRANNIS, D.C., A CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:GRANNIS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:HARRIMAN
Authorized Official - Last Name:GRANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-448-8599
Mailing Address - Street 1:24541 PACIFIC PARK DR STE 290
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3058
Mailing Address - Country:US
Mailing Address - Phone:949-448-8599
Mailing Address - Fax:949-448-8595
Practice Address - Street 1:24541 PACIFIC PARK DR STE 290
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3058
Practice Address - Country:US
Practice Address - Phone:949-448-8599
Practice Address - Fax:949-448-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104849793OtherNPI FOR GORDON GRANNIS
CA1104849793OtherNPI FOR GORDON GRANNIS
CA=========Medicare ID - Type Unspecified