Provider Demographics
NPI:1467523316
Name:CUSACK CHIROPRACTIC PROF CORP
Entity Type:Organization
Organization Name:CUSACK CHIROPRACTIC PROF CORP
Other - Org Name:CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:925-945-0555
Mailing Address - Street 1:2801 YGNACIO VALLEY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598
Mailing Address - Country:US
Mailing Address - Phone:925-945-0555
Mailing Address - Fax:925-945-1873
Practice Address - Street 1:2801 YGNACIO VALLEY ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-945-0555
Practice Address - Fax:925-945-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18025ZMedicare ID - Type Unspecified