Provider Demographics
NPI:1912116765
Name:C. GREG HENDERSON DC INC A CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:C. GREG HENDERSON DC INC A CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C.
Authorized Official - Middle Name:GREG
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-728-2800
Mailing Address - Street 1:5256 S MISSION RD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-3614
Mailing Address - Country:US
Mailing Address - Phone:760-728-2800
Mailing Address - Fax:760-509-1313
Practice Address - Street 1:5256 S MISSION RD
Practice Address - Street 2:SUITE 406
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3614
Practice Address - Country:US
Practice Address - Phone:760-728-2800
Practice Address - Fax:760-509-1313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0135480OtherBLUE SHIELD
CAWDC1421Medicare PIN
CAWDC1421Medicare ID - Type Unspecified