Provider Demographics
NPI:1154735710
Name:STAYBERG, GREGORY SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SCOTT
Last Name:STAYBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 ARDATH AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-1525
Mailing Address - Country:US
Mailing Address - Phone:310-650-1104
Mailing Address - Fax:
Practice Address - Street 1:1870 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4612
Practice Address - Country:US
Practice Address - Phone:213-515-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34271111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor