Provider Demographics
NPI:1851325740
Name:GOUR, MARK OLIVER (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:OLIVER
Last Name:GOUR
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:PO BOX 2479
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93447-2479
Mailing Address - Country:US
Mailing Address - Phone:661-587-9741
Mailing Address - Fax:
Practice Address - Street 1:4750 COFFEE RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-5034
Practice Address - Country:US
Practice Address - Phone:661-587-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24135111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0241350Medicare ID - Type Unspecified