Provider Demographics
NPI:1225236508
Name:MASSICOTTE, JUSTIN ROBERT JOSEPH
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ROBERT JOSEPH
Last Name:MASSICOTTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 BOUL. DECARIE
Mailing Address - Street 2:
Mailing Address - City:MONTREAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H4P2H1
Mailing Address - Country:CA
Mailing Address - Phone:563-676-6767
Mailing Address - Fax:563-676-6767
Practice Address - Street 1:1000 BRADY ST
Practice Address - Street 2:PCC BOX 527
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-5214
Practice Address - Country:US
Practice Address - Phone:563-676-6767
Practice Address - Fax:563-676-6767
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IANONE111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor