Provider Demographics
NPI:1568519460
Name:SANNES, GARY L (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:SANNES
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 1:4590 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-464-9880
Mailing Address - Fax:909-591-4720
Practice Address - Street 1:4590 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-464-9880
Practice Address - Fax:909-591-4720
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0211110Medicare ID - Type UnspecifiedMEDICARE
CADC021111Medicare Oscar/Certification