Provider Demographics
NPI:1073693040
Name:PICOU, GREGORY KEVIN (DC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:KEVIN
Last Name:PICOU
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 1:9344 THREE RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4268
Mailing Address - Country:US
Mailing Address - Phone:228-865-9898
Mailing Address - Fax:228-863-5616
Practice Address - Street 1:9344 THREE RIVERS RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4268
Practice Address - Country:US
Practice Address - Phone:228-865-9898
Practice Address - Fax:228-863-5616
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0916111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800075040OtherTAX ID