Provider Demographics
NPI:1154407435
Name:BASTYR, TERESA IRENE (DC)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:IRENE
Last Name:BASTYR
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 PRAIRIE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-7609
Mailing Address - Country:US
Mailing Address - Phone:651-270-2066
Mailing Address - Fax:
Practice Address - Street 1:2507 PRAIRIE OAK TRL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-7609
Practice Address - Country:US
Practice Address - Phone:651-270-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3795111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor