Basic Information
Provider Information | |||||||||
NPI: | 1043252349 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GLADDEN HUNTER CHIROPRACTIC CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 990 ENCHANTED WAY | ||||||||
Address2: | SUITE 101A | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930650915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055202929 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 990 ENCHANTED WAY | ||||||||
Address2: | SUITE 101A | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930650915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055202929 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GLADDEN | ||||||||
AuthorizedOfficialFirstName: | LEAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8055202929 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 27915 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 111N00000X | 25341 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 225100000X | 30034 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | GL ZZZ66532Z | 01 | CA | BLUE SHIELD PHYSICAL | OTHER | ZZZ66531Z | 01 | CA | BLUE SHIELD CHIRO | OTHER |