Provider Demographics
NPI:1912202904
Name:DEFRIES, CRAIG BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:BRIAN
Last Name:DEFRIES
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 1:4540 E BASELINE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4613
Mailing Address - Country:US
Mailing Address - Phone:480-272-8944
Mailing Address - Fax:480-237-5682
Practice Address - Street 1:4540 E BASELINE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4613
Practice Address - Country:US
Practice Address - Phone:480-272-8944
Practice Address - Fax:480-237-5682
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8358OtherLICENSE