Provider Demographics
NPI:1235171844
Name:HUSTON, CLINTON LAVAR (DC)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:LAVAR
Last Name:HUSTON
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 1:21321 E OCOTILLO RD
Mailing Address - Street 2:STE 121
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5994
Mailing Address - Country:US
Mailing Address - Phone:480-988-0668
Mailing Address - Fax:
Practice Address - Street 1:21321 E OCOTILLO RD
Practice Address - Street 2:STE 121
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5994
Practice Address - Country:US
Practice Address - Phone:480-987-9740
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7550111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102996Medicare PIN
AZV04939Medicare UPIN