Provider Demographics
NPI:1902942352
Name:PENDERGRASS, DOUG (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUG
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROAD 3540
Mailing Address - Street 2:
Mailing Address - City:FLORA VISTA
Mailing Address - State:NM
Mailing Address - Zip Code:87415-9601
Mailing Address - Country:US
Mailing Address - Phone:505-860-0862
Mailing Address - Fax:505-860-0862
Practice Address - Street 1:12 ROAD 3540
Practice Address - Street 2:
Practice Address - City:FLORA VISTA
Practice Address - State:NM
Practice Address - Zip Code:87415-9601
Practice Address - Country:US
Practice Address - Phone:505-860-0862
Practice Address - Fax:505-860-0862
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X8022OtherBCBS