Provider Demographics
NPI:1376525949
Name:LOUSTALET, MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LOUSTALET
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 457
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:96022-0457
Mailing Address - Country:US
Mailing Address - Phone:530-347-6407
Mailing Address - Fax:
Practice Address - Street 1:20633 GAS POINT RD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:CA
Practice Address - Zip Code:96022-9296
Practice Address - Country:US
Practice Address - Phone:530-347-6407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0196580OtherBLUE SHIELD INDV
DC0196580OtherBLUE SHIELD INDV
DC019658Medicare ID - Type Unspecified