Healthcare Provider Details

I. General information

NPI: 1619298395
Provider Name (Legal Business Name): GREGORY CHIROPRACTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604 I 55 S
BYRAM MS
39272-9402
US

IV. Provider business mailing address

5604 I 55 S
BYRAM MS
39272-9402
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-5767
  • Fax: 601-372-4031
Mailing address:
  • Phone: 601-373-5767
  • Fax: 601-372-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number589
License Number StateMS

VIII. Authorized Official

Name: DR. ROGER MILTON GREGORY III
Title or Position: OWNER
Credential: D.C.
Phone: 601-373-5767