Provider Demographics
NPI:1356453047
Name:PENNISTON, GREGORY K (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:K
Last Name:PENNISTON
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 1:6563 E. 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-745-8101
Mailing Address - Fax:
Practice Address - Street 1:6563 E 22ND ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5106
Practice Address - Country:US
Practice Address - Phone:520-745-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3199111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ75423Medicare ID - Type Unspecified