Provider Demographics
NPI:1194874271
Name:GISLASON, ERIC J (DC)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:GISLASON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 HWY 93 SOUTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937
Mailing Address - Country:US
Mailing Address - Phone:406-862-9700
Mailing Address - Fax:406-862-9700
Practice Address - Street 1:5875 HWY 93 SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937
Practice Address - Country:US
Practice Address - Phone:406-862-9700
Practice Address - Fax:406-862-9700
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT761111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT161466Medicaid
MT41841OtherBLUE CROSS BLUE SHIELD