Provider Demographics
NPI:1427418375
Name:BOSTROM CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:BOSTROM CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BJORN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:831-459-8434
Mailing Address - Street 1:149 JOSEPHINE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2775
Mailing Address - Country:US
Mailing Address - Phone:831-459-8434
Mailing Address - Fax:831-459-8434
Practice Address - Street 1:149 JOSEPHINE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2775
Practice Address - Country:US
Practice Address - Phone:831-459-8434
Practice Address - Fax:831-459-8434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA120021Medicare PIN