Provider Demographics
NPI:1508070467
Name:TLC FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:TLC FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:MCCUISTION
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-502-9278
Mailing Address - Street 1:430 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1240
Mailing Address - Country:US
Mailing Address - Phone:208-745-8760
Mailing Address - Fax:
Practice Address - Street 1:430 N STATE ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1240
Practice Address - Country:US
Practice Address - Phone:208-745-8760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3449671202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty