Provider Demographics
NPI:1407938798
Name:GUSTAFSON, RYAN DENNIS (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:DENNIS
Last Name:GUSTAFSON
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 1:1910 LUCILLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4693
Mailing Address - Country:US
Mailing Address - Phone:928-753-2047
Mailing Address - Fax:928-753-2020
Practice Address - Street 1:1910 LUCILLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4693
Practice Address - Country:US
Practice Address - Phone:928-753-2047
Practice Address - Fax:928-753-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7156111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3142303OtherAETNA
AZAZ0937240OtherBC/BS OF AZ
CA1212439OtherCHIROSOURCE OF CA.
AZ1Z5906OtherHEALTH NET
AZ5291063OtherCCN/FIRST HEALTH
AZ692659Medicaid
AZ229944OtherAP/IPA (AHCCCS)
AZU87611Medicare UPIN