Provider Demographics
NPI:1902959778
Name:GREATHOUSE CHIROPRACTIC INC
Entity Type:Organization
Organization Name:GREATHOUSE CHIROPRACTIC INC
Other - Org Name:GREATHOUSE CHIROPRACTIC INC
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:949-481-8282
Mailing Address - Street 1:130 AVENIDA CABRILLO
Mailing Address - Street 2:STE C
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5509
Mailing Address - Country:US
Mailing Address - Phone:949-481-8282
Mailing Address - Fax:949-218-6303
Practice Address - Street 1:130 AVENIDA CABRILLO
Practice Address - Street 2:STE C
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5509
Practice Address - Country:US
Practice Address - Phone:949-481-8282
Practice Address - Fax:949-218-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28049111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherCHIROPRACTIC
CA=========OtherCHIROPRACTIC
CAV47495Medicare UPIN