=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235241944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON H GRANNIS, D.C., A CHIROPRACTIC PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24541 PACIFIC PARK DR STE 290
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-448-8599
-----------------------------------------------------
Fax | 949-448-8595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24541 PACIFIC PARK DR STE 290
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-448-8599
-----------------------------------------------------
Fax | 949-448-8595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GORDON HARRIMAN GRANNIS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 949-448-8599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC12688
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------