Provider Demographics
NPI:1992857353
Name:GANTT, J PATRICK III (DC)
Entity Type:Individual
Prefix:DR
First Name:J PATRICK
Middle Name:
Last Name:GANTT
Suffix:III
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 1:221 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-5038
Mailing Address - Country:US
Mailing Address - Phone:805-925-6665
Mailing Address - Fax:805-925-6665
Practice Address - Street 1:221 S PINE ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5038
Practice Address - Country:US
Practice Address - Phone:805-925-6665
Practice Address - Fax:805-925-6665
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18802111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC18802OtherCHIROPRACTIC NUMBER
CAU28909Medicare UPIN