Provider Demographics
NPI:1902939648
Name:MALLETT, GREGG S (DC, ATC, CKTP)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:S
Last Name:MALLETT
Suffix:
Gender:M
Credentials:DC, ATC, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22661 LAMBERT ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1612
Mailing Address - Country:US
Mailing Address - Phone:949-916-9742
Mailing Address - Fax:949-716-2694
Practice Address - Street 1:22661 LAMBERT ST
Practice Address - Street 2:SUITE 207
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1612
Practice Address - Country:US
Practice Address - Phone:949-916-9742
Practice Address - Fax:949-716-2694
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2812111N00000X
CA30918111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU74422Medicare UPIN
MAY45232Medicare ID - Type Unspecified