MEDICARE: MR. GARY DE FOREST D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	D.C. 16331	CA

General Provider Information

NPI Number	:	1033238365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY DE FOREST D.C.

Provider Business Mailing Address
First Line	:	2304 SAN DIEGO AVE STE C
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2896
Country	:	US
Telephone Number	:	619-291-2462
Fax Number	:	619-291-9242

Provider Business Practice Location Address
First Line	:	2304 SAN DIEGO AVE STE C
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2896
Country	:	US
Telephone Number	:	619-291-2462
Fax Number	:	619-291-9242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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