Provider Demographics
NPI:1255452215
Name:GUSTAFSON, JOSEPH SCOTT SR (LAC)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:SCOTT
Last Name:GUSTAFSON
Suffix:SR
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 PIKA TRAIL
Mailing Address - Street 2:UNIT A
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022
Mailing Address - Country:US
Mailing Address - Phone:715-425-2694
Mailing Address - Fax:
Practice Address - Street 1:1475 HWY 65
Practice Address - Street 2:PAIN MANAGEMENT ACUPUNCTURE OF ST CROIX
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017
Practice Address - Country:US
Practice Address - Phone:715-425-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI473055171100000X
MN1367171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist