Provider Demographics
NPI:1396941704
Name:GONSTEAD PERFORMANCE CHIROPRACTIC
Entity type:Organization
Organization Name:GONSTEAD PERFORMANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TRAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-810-4020
Mailing Address - Street 1:8457 E MCDONALD DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-6334
Mailing Address - Country:US
Mailing Address - Phone:480-751-6199
Mailing Address - Fax:480-751-6197
Practice Address - Street 1:8457 E MCDONALD DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-6334
Practice Address - Country:US
Practice Address - Phone:480-751-6199
Practice Address - Fax:480-751-6197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ103971OtherMEDICARE PTAN
AZZ103971Medicare PIN
AZZ103971OtherMEDICARE PTAN