Provider Demographics
NPI:1972512184
Name:GROOTENDORST CHIROPRACTIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GROOTENDORST CHIROPRACTIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GROOTENDORST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:559-674-8892
Mailing Address - Street 1:900 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-4555
Mailing Address - Country:US
Mailing Address - Phone:559-674-8892
Mailing Address - Fax:559-674-1389
Practice Address - Street 1:900 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637
Practice Address - Country:US
Practice Address - Phone:559-674-8892
Practice Address - Fax:559-674-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000470OtherMEDI-CAL
CAGDC000470OtherMEDI-CAL