Provider Demographics
NPI:1275622730
Name:SIMON, TRACY RAE (DOCTOR OF CHIROPRATI)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RAE
Last Name:SIMON
Suffix:
Gender:F
Credentials:DOCTOR OF CHIROPRATI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 W MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3620
Mailing Address - Country:US
Mailing Address - Phone:707-448-9661
Mailing Address - Fax:707-448-9663
Practice Address - Street 1:530 W MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3620
Practice Address - Country:US
Practice Address - Phone:707-448-9661
Practice Address - Fax:707-448-9663
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88313Medicare UPIN