Provider Demographics
NPI:1013985514
Name:MCCUISTION, TRACY A (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:A
Last Name:MCCUISTION
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 1:430 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1240
Mailing Address - Country:US
Mailing Address - Phone:208-745-7374
Mailing Address - Fax:
Practice Address - Street 1:430 N STATE ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1240
Practice Address - Country:US
Practice Address - Phone:208-745-7374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3449761202111N00000X
IDCHIA-1404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000056234Medicare ID - Type Unspecified