Provider Demographics
NPI:1992862189
Name:WEESSIES, GARY JORDAN (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JORDAN
Last Name:WEESSIES
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 1:4843 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2760
Mailing Address - Country:US
Mailing Address - Phone:951-682-4404
Mailing Address - Fax:951-682-4406
Practice Address - Street 1:4843 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2760
Practice Address - Country:US
Practice Address - Phone:951-682-4404
Practice Address - Fax:951-682-4406
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0249321Medicare ID - Type Unspecified