Provider Demographics
NPI:1023369568
Name:CUSACK CHIROPRACTIC
Entity Type:Organization
Organization Name:CUSACK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-945-0555
Mailing Address - Street 1:2801 YGNACIO VALLEY RD
Mailing Address - Street 2:STE. B
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-3587
Mailing Address - Country:US
Mailing Address - Phone:925-945-0555
Mailing Address - Fax:925-945-1873
Practice Address - Street 1:2801 YGNACIO VALLEY RD
Practice Address - Street 2:STE. B
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3587
Practice Address - Country:US
Practice Address - Phone:925-945-0555
Practice Address - Fax:925-945-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18025ZMedicare PIN