Provider Demographics
NPI:1962585943
Name:PRESTON, STACEY ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANNE
Last Name:PRESTON
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 1:902 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-2120
Mailing Address - Country:US
Mailing Address - Phone:510-525-2715
Mailing Address - Fax:510-525-2306
Practice Address - Street 1:902 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2120
Practice Address - Country:US
Practice Address - Phone:510-525-2715
Practice Address - Fax:510-525-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0236910OtherBLUE SHIELD OF CALIFORNIA
CADC0236910Medicare ID - Type Unspecified