Provider Demographics
NPI:1609086560
Name:FOURZON, RICHARD GREGORY (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GREGORY
Last Name:FOURZON
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 1:585 WEST COLLEGE AVENUE
Mailing Address - Street 2:SUITE: B
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5060
Mailing Address - Country:US
Mailing Address - Phone:707-579-2234
Mailing Address - Fax:707-579-6001
Practice Address - Street 1:585 WEST COLLEGE AVENUE
Practice Address - Street 2:SUITE: B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5060
Practice Address - Country:US
Practice Address - Phone:707-579-2234
Practice Address - Fax:707-579-6001
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18409111N00000X
CADC0184090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU30981Medicare UPIN