Provider Demographics
NPI:1205868569
Name:WALL, GARY VINCENT
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:VINCENT
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13380 PLACID HILL DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-8926
Mailing Address - Country:US
Mailing Address - Phone:951-737-1252
Mailing Address - Fax:
Practice Address - Street 1:535 W 9TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3218
Practice Address - Country:US
Practice Address - Phone:951-737-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor