Provider Demographics
NPI:1790227866
Name:MERRYMAN, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MERRYMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 WAGONHAMMER LN
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5327
Mailing Address - Country:US
Mailing Address - Phone:307-299-2941
Mailing Address - Fax:
Practice Address - Street 1:201 W LAKEWAY RD
Practice Address - Street 2:SUITE 211
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6361
Practice Address - Country:US
Practice Address - Phone:307-217-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY763111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation