Provider Demographics
NPI:1093033706
Name:GONSTEAD FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:GONSTEAD FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-940-7167
Mailing Address - Street 1:4275 HARLAN ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5119
Mailing Address - Country:US
Mailing Address - Phone:303-940-7167
Mailing Address - Fax:303-940-7258
Practice Address - Street 1:4275 HARLAN ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5119
Practice Address - Country:US
Practice Address - Phone:303-940-7167
Practice Address - Fax:303-940-7258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4777111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty