Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAHLSTROM, D.C., L.A.C. INC
Provider Other First Name:
ERIC
Provider Other Middle Name:
P.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C, L. AC.
Provider Other Last Name Type Code:
2