Healthcare Provider Details

I. General information

NPI: 1043245574
Provider Name (Legal Business Name): TODD ROBERT CUSTER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 W MONTGOMERY ST
WILLIS TX
77378-8830
US

IV. Provider business mailing address

804 W MONTGOMERY ST
WILLIS TX
77378-8830
US

V. Phone/Fax

Practice location:
  • Phone: 936-856-8908
  • Fax: 936-856-8022
Mailing address:
  • Phone: 936-856-8908
  • Fax: 936-856-8022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number10274
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: