Provider Demographics
NPI:1922101179
Name:GONSTEAD FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:GONSTEAD FAMILY CHIROPRACTIC, LLC
Other - Org Name:GONSTEAD FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-747-0770
Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:BUILDING C SUITE 222
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-747-0770
Mailing Address - Fax:801-747-0771
Practice Address - Street 1:1121 E 3900 S
Practice Address - Street 2:BUILDING C SUITE 222
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1214
Practice Address - Country:US
Practice Address - Phone:801-747-0770
Practice Address - Fax:801-747-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369441-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005758401Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
UT000057584Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER