Provider Demographics
NPI:1326207804
Name:MITCHELL, GARY A (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:MITCHELL
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 1:1752 OCEAN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4950
Mailing Address - Country:US
Mailing Address - Phone:310-399-3342
Mailing Address - Fax:310-399-8832
Practice Address - Street 1:1752 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-4950
Practice Address - Country:US
Practice Address - Phone:310-399-3342
Practice Address - Fax:310-399-8832
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13357111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician