Provider Demographics
NPI:1972613370
Name:ANDERSEN, GRAHAM DOUGLAS (DC, DACBSP, CCN)
Entity Type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:DOUGLAS
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DC, DACBSP, CCN
Other - Prefix:
Other - First Name:G
Other - Middle Name:DOUGLAS
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, DACBSP, CCN
Mailing Address - Street 1:916 E IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5612
Mailing Address - Country:US
Mailing Address - Phone:714-990-0824
Mailing Address - Fax:714-990-1917
Practice Address - Street 1:916 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5612
Practice Address - Country:US
Practice Address - Phone:714-990-0824
Practice Address - Fax:714-990-1917
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17373111N00000X, 111NS0005X
CA3910133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT064570Medicare UPIN