Provider Demographics
NPI:1619065018
Name:PEREA, GREGORY LOUIS (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LOUIS
Last Name:PEREA
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 1:1112 ALVARADO DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6502
Mailing Address - Country:US
Mailing Address - Phone:505-255-6357
Mailing Address - Fax:505-255-6357
Practice Address - Street 1:1112 ALVARADO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6502
Practice Address - Country:US
Practice Address - Phone:505-255-6357
Practice Address - Fax:505-255-6357
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM535111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2671662Medicare ID - Type Unspecified