Provider Demographics
NPI:1912028200
Name:GASTON FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:GASTON FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-922-5060
Mailing Address - Street 1:625 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2220
Mailing Address - Country:US
Mailing Address - Phone:231-922-5060
Mailing Address - Fax:231-922-5062
Practice Address - Street 1:625 2ND ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2220
Practice Address - Country:US
Practice Address - Phone:231-922-5060
Practice Address - Fax:231-922-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006073111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B81220OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0B81220OtherBLUE CROSS BLUE SHIELD OF MICHIGAN