Basic Information
| Provider Information | |||||||||
| NPI: | 1457578528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | CHIRSTOPHER | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 TEJAS PL | ||||||||
| Address2: | PO BOX 430 | ||||||||
| City: | NIPOMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934449123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059293211 | ||||||||
| FaxNumber: | 8059296440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 BISHOP ST | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052691300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC 19668 | CA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | AS226Z | 01 | CA | PTAN W1508E | OTHER | 551983 | 01 | CA | MEDICARE | OTHER | FHC71031F | 05 | CA | MEDICAID |