Provider Demographics
NPI:1801070628
Name:MISUSTIN CHIROPRACTIC PC
Entity type:Organization
Organization Name:MISUSTIN CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:MISUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-753-2840
Mailing Address - Street 1:1415 N 400 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7539
Mailing Address - Country:US
Mailing Address - Phone:435-753-2840
Mailing Address - Fax:435-787-9422
Practice Address - Street 1:1415 N 400 E
Practice Address - Street 2:SUITE A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7539
Practice Address - Country:US
Practice Address - Phone:435-753-2840
Practice Address - Fax:435-787-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320260-1202111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT554155506001Medicaid
UT554155506001Medicaid