Provider Demographics
NPI:1629003017
Name:C.S. GONSTEAD CHIROPRACTIC FOUNDATION, INC
Entity type:Organization
Organization Name:C.S. GONSTEAD CHIROPRACTIC FOUNDATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-437-5585
Mailing Address - Street 1:PO BOX 46
Mailing Address - Street 2:1505 SPRINGDALE ST
Mailing Address - City:MT. HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572
Mailing Address - Country:US
Mailing Address - Phone:608-437-5585
Mailing Address - Fax:608-437-7041
Practice Address - Street 1:1505 SPRINGDALE ST
Practice Address - Street 2:
Practice Address - City:MT. HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572
Practice Address - Country:US
Practice Address - Phone:608-437-5585
Practice Address - Fax:608-437-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0000035795Medicare PIN