=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548497340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM C. GUSTAFSON, D.C., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2009
-----------------------------------------------------
Last Update Date | 07/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 199 COON RAPIDS BLVD SUITE 315
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-717-9510
-----------------------------------------------------
Fax | 763-717-2988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 199 COON RAPIDS BLVD SUITE 315
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-5861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-717-9510
-----------------------------------------------------
Fax | 763-717-2988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM C GUSTAFSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 763-717-9510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2782
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------