Provider Demographics
NPI:1649306036
Name:CONRAD, GREGORY ISAAC (DC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ISAAC
Last Name:CONRAD
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 1:11130 MAGNOLIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:951-785-1133
Mailing Address - Fax:951-785-5427
Practice Address - Street 1:11130 MAGNOLIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505
Practice Address - Country:US
Practice Address - Phone:951-785-1133
Practice Address - Fax:951-785-5427
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0163150Medicare ID - Type Unspecified