Provider Demographics
NPI:1013121946
Name:SIMMONS, GREGORY CARL (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CARL
Last Name:SIMMONS
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 1:334 SHAW AVE
Mailing Address - Street 2:SUITE 133
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3847
Mailing Address - Country:US
Mailing Address - Phone:559-905-7508
Mailing Address - Fax:559-325-8565
Practice Address - Street 1:334 SHAW AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3847
Practice Address - Country:US
Practice Address - Phone:559-905-7508
Practice Address - Fax:559-325-8565
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21510111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1758336Medicaid
CADC0215100Medicare PIN