Provider Demographics
NPI:1598002487
Name:DR MJ GONSTEAD LLC
Entity Type:Organization
Organization Name:DR MJ GONSTEAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:GONSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-832-2223
Mailing Address - Street 1:503 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6479
Mailing Address - Country:US
Mailing Address - Phone:715-832-2223
Mailing Address - Fax:715-832-7416
Practice Address - Street 1:503 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6479
Practice Address - Country:US
Practice Address - Phone:715-832-2223
Practice Address - Fax:715-832-7416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2063-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI3066Medicare UPIN