Provider Demographics
NPI:1700924131
Name:CALLIS, GREGORY B (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:B
Last Name:CALLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2053 E FAIRVIEW AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8043
Mailing Address - Country:US
Mailing Address - Phone:208-895-0977
Mailing Address - Fax:208-895-0978
Practice Address - Street 1:2053 E FAIRVIEW AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8043
Practice Address - Country:US
Practice Address - Phone:208-895-0977
Practice Address - Fax:208-895-0978
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-849111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010025108Medicare UPIN
IDC-849-7Medicare UPIN