Provider Demographics
NPI:1558408708
Name:DEGRUCHY, JOHN L (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:DEGRUCHY
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 1:2114 HYPERION AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-4708
Mailing Address - Country:US
Mailing Address - Phone:323-662-4401
Mailing Address - Fax:
Practice Address - Street 1:2114 HYPERION AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-4708
Practice Address - Country:US
Practice Address - Phone:323-662-4401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC13763Medicare PIN
CAT17597Medicare UPIN