Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 10309 | CA |
NPI | 1427075076 |
---|---|
Provider Name | Dr. Derek F. I. Greensides |
First Address | San Bruno, CA 94066-3443 |
Second Address | San Bruno, CA 94066-3443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 08/07/2007 |