1255452215 NPI number — MR. JOSEPH SCOTT GUSTAFSON SR. LAC

Table of content: MR. JOSEPH SCOTT GUSTAFSON SR. LAC (NPI 1255452215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255452215 NPI number — MR. JOSEPH SCOTT GUSTAFSON SR. LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
JOSEPH
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255452215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 PIKA TRAIL
Provider Second Line Business Mailing Address:
UNIT A
Provider Business Mailing Address City Name:
RIVER FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-425-2694
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 HWY 65
Provider Second Line Business Practice Location Address:
PAIN MANAGEMENT ACUPUNCTURE OF ST CROIX
Provider Business Practice Location Address City Name:
NEW RICHMOND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-425-2694
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  473055 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: 1367 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)