Provider Demographics
NPI:1447365655
Name:GUSTIN, MARY JO (DC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JO
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1503
Mailing Address - Country:US
Mailing Address - Phone:310-873-4422
Mailing Address - Fax:310-873-4434
Practice Address - Street 1:11710 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1503
Practice Address - Country:US
Practice Address - Phone:310-873-4422
Practice Address - Fax:310-873-4434
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH263-0796111N00000X
CA17484111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30251443Medicaid
U75926Medicare UPIN
NH30251443Medicaid