Provider Demographics
NPI:1912529082
Name:GROSS, TRACI (DC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:GROSS
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 1:1460 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2181
Mailing Address - Country:US
Mailing Address - Phone:317-749-0677
Mailing Address - Fax:317-735-8753
Practice Address - Street 1:1460 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2181
Practice Address - Country:US
Practice Address - Phone:317-749-0677
Practice Address - Fax:317-735-8753
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003162A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty