Provider Demographics
NPI:1821494733
Name:DASTRUP, DANIEL (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DASTRUP
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-4578
Mailing Address - Country:US
Mailing Address - Phone:435-527-0987
Mailing Address - Fax:
Practice Address - Street 1:57 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754-4578
Practice Address - Country:US
Practice Address - Phone:435-527-0987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9169105-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor