Provider Demographics
NPI:1992574677
Name:GAGNON, SERGE (DC)
Entity type:Individual
Prefix:DR
First Name:SERGE
Middle Name:
Last Name:GAGNON
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 1:12304 SANTA MONICA BLVD # 311
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2551
Mailing Address - Country:US
Mailing Address - Phone:310-430-5438
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD # 311
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2551
Practice Address - Country:US
Practice Address - Phone:310-430-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor