Provider Demographics
NPI:1306966775
Name:GOREN, GARY EARL (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:EARL
Last Name:GOREN
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 1:5279 AMHURST DR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-1621
Mailing Address - Country:US
Mailing Address - Phone:770-840-7121
Mailing Address - Fax:
Practice Address - Street 1:7050 JIMMY CARTER BLVD
Practice Address - Street 2:SUITE 121AA
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3257
Practice Address - Country:US
Practice Address - Phone:770-840-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO001356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCBZXMedicare UPIN
GA143513Medicare ID - Type Unspecified