Provider Demographics
NPI:1861544108
Name:BUSH, GARY WAYNE (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:BUSH
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 1:2402 LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-5008
Mailing Address - Country:US
Mailing Address - Phone:863-965-2999
Mailing Address - Fax:
Practice Address - Street 1:2402 LAKE DR NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-5008
Practice Address - Country:US
Practice Address - Phone:863-965-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 0003968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88953Medicare ID - Type Unspecified