Basic Information
| Provider Information | |||||||||
| NPI: | 1316379308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LEOR | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4233628684 | ||||||||
| Practice Location | |||||||||
| Address1: | 3935 BRIAN JORDAN PL | ||||||||
| Address2: | STE 119 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368850440 | ||||||||
| FaxNumber: | 3368850442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 02/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011099 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P15717 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.