Provider Demographics
NPI:1942211495
Name:HALL, GARY W (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:HALL
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 1:200 AUTO CENTER CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-1573
Mailing Address - Country:US
Mailing Address - Phone:209-527-5433
Mailing Address - Fax:209-527-3128
Practice Address - Street 1:200 AUTO CENTER CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-1573
Practice Address - Country:US
Practice Address - Phone:209-527-5433
Practice Address - Fax:209-527-3128
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 11200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC11200Medicare ID - Type UnspecifiedPROVIDER NUMBER