Provider Demographics
NPI:1619419413
Name:WEAVER-GOURDEAU, GARRISON (DC)
Entity Type:Individual
Prefix:
First Name:GARRISON
Middle Name:
Last Name:WEAVER-GOURDEAU
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 1:40967 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6031
Mailing Address - Country:US
Mailing Address - Phone:951-296-5286
Mailing Address - Fax:951-296-5287
Practice Address - Street 1:40967 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6031
Practice Address - Country:US
Practice Address - Phone:951-265-2238
Practice Address - Fax:951-296-5287
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor