Provider Demographics
NPI:1669698874
Name:WATERS, SANDRA (DC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DARBY ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-9156
Mailing Address - Country:US
Mailing Address - Phone:707-464-2811
Mailing Address - Fax:707-464-8211
Practice Address - Street 1:200 DARBY ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-9156
Practice Address - Country:US
Practice Address - Phone:707-464-2811
Practice Address - Fax:707-464-8211
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14804111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0148040OtherBLUE SHIELD CA