Provider Demographics
NPI:1972812642
Name:OLD TARPON CHIROPRACTIC PA
Entity type:Organization
Organization Name:OLD TARPON CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:727-942-1618
Mailing Address - Street 1:4630 DARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34690-3906
Mailing Address - Country:US
Mailing Address - Phone:727-942-1618
Mailing Address - Fax:
Practice Address - Street 1:4630 DARLINGTON RD
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690-3906
Practice Address - Country:US
Practice Address - Phone:727-942-1618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH1469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL89628Medicare UPIN