Healthcare Provider Details

I. General information

NPI: 1568545580
Provider Name (Legal Business Name): GREGG ALLEN MEDEIROS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1196 ELMWOOD AVE
PROVIDENCE RI
02907-3716
US

IV. Provider business mailing address

43 MOUNTAIN AVE
RIVERSIDE RI
02915-5015
US

V. Phone/Fax

Practice location:
  • Phone: 401-461-1600
  • Fax: 401-461-3500
Mailing address:
  • Phone: 401-440-4228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDCP00545
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberDCP00545
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: