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General NPI Number Information
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NPI Number | 1972812642
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Entity Type | Organization
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Legal Business Name | OLD TARPON CHIROPRACTIC PA
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 09/29/2010
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Provider Practice Location Address
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Address Line | 4630 DARLINGTON RD
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City | HOLIDAY
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State | FL
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Zip | 34690-3906
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Country | US
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Telephone | 727-942-1618
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Fax |
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Provider Business Mailing Address
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Address Line | 4630 DARLINGTON RD
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City | HOLIDAY
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State | FL
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Zip | 34690-3906
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Country | US
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Telephone | 727-942-1618
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ALTON J GUSTAFSON
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Credential | D C
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Telephone | 727-942-1618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH1469
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License Number State | FL
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