Provider Demographics
NPI:1093939555
Name:BUSTIN, GARY LLOYD (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LLOYD
Last Name:BUSTIN
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-0304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 W 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2630
Practice Address - Country:US
Practice Address - Phone:909-599-0237
Practice Address - Fax:909-599-0237
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14561111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology