Provider Demographics
NPI:1376823666
Name:DIAMOND, GREGG MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:MICHAEL
Last Name:DIAMOND
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 1:806 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3224
Mailing Address - Country:US
Mailing Address - Phone:415-482-6577
Mailing Address - Fax:415-482-6539
Practice Address - Street 1:806 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3224
Practice Address - Country:US
Practice Address - Phone:415-482-6577
Practice Address - Fax:415-482-6539
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor