Provider Demographics
NPI:1568233120
Name:WADDELL, GABRIEL SEBASTIAN (DC)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:SEBASTIAN
Last Name:WADDELL
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 1:1109 MISSION PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3700
Mailing Address - Country:US
Mailing Address - Phone:601-636-8771
Mailing Address - Fax:601-634-1004
Practice Address - Street 1:1109 MISSION PARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3700
Practice Address - Country:US
Practice Address - Phone:601-636-8771
Practice Address - Fax:601-634-1004
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor