Provider Demographics
NPI:1881078582
Name:FERNANDEZ, GRACE MADARANG (DC)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:MADARANG
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 PARKSHORE DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-292-8657
Mailing Address - Fax:916-292-8657
Practice Address - Street 1:153 PARKSHORE DRIVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-292-8657
Practice Address - Fax:916-292-8657
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8556099960Medicaid
CA8556099960Medicare UPIN
CA8556099960Medicaid
CA8556099960Medicare NSC