Provider Demographics
NPI:1790723518
Name:HARDEMAN, GARY RUSSELL (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RUSSELL
Last Name:HARDEMAN
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 1:32246 CLINTON KEITH RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7320
Mailing Address - Country:US
Mailing Address - Phone:951-678-9063
Mailing Address - Fax:951-678-2893
Practice Address - Street 1:32246 CLINTON KEITH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7320
Practice Address - Country:US
Practice Address - Phone:951-677-8997
Practice Address - Fax:951-678-2893
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC21349Medicare ID - Type Unspecified
CAU25457Medicare UPIN