Provider Demographics
NPI:1003970930
Name:KINGMAN CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:KINGMAN CHIROPRACTIC CLINIC PC
Other - Org Name:DENNIS D AND RYAN D GUSTAFSON DC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-753-2047
Mailing Address - Street 1:1910 LUCILLE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4693
Mailing Address - Country:US
Mailing Address - Phone:928-753-2047
Mailing Address - Fax:928-753-2020
Practice Address - Street 1:1910 LUCILLE AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4693
Practice Address - Country:US
Practice Address - Phone:928-753-2047
Practice Address - Fax:928-753-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty