Healthcare Provider Details

I. General information

NPI: 1235169053
Provider Name (Legal Business Name): INNERSPORT CHIROPRACTIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 ADDISON ST STE 102
BERKELEY CA
94702-1749
US

IV. Provider business mailing address

1250 ADDISON ST STE 102
BERKELEY CA
94702-1749
US

V. Phone/Fax

Practice location:
  • Phone: 510-883-1126
  • Fax: 510-883-9926
Mailing address:
  • Phone: 510-883-1126
  • Fax: 510-883-9926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC-27916
License Number StateCA

VIII. Authorized Official

Name: DR. JESSICA LEE GREAUX
Title or Position: OWNER
Credential: DC
Phone: 510-883-1126