Provider Demographics
NPI:1528037066
Name:BATES, GREGORY CLYDE (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CLYDE
Last Name:BATES
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 1:28100 MODJESKA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SILVERADO
Mailing Address - State:CA
Mailing Address - Zip Code:92676-9744
Mailing Address - Country:US
Mailing Address - Phone:714-544-9304
Mailing Address - Fax:714-710-9010
Practice Address - Street 1:131 N TUSTIN AVE STE 104
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2937
Practice Address - Country:US
Practice Address - Phone:714-544-3904
Practice Address - Fax:714-710-9010
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T17810Medicare UPIN
CADC14548Medicare ID - Type Unspecified