Provider Demographics
NPI:1013180686
Name:PAYNE, TOMMY DALE
Entity Type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:DALE
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:TOM
Other - Middle Name:D
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 23040
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-0040
Mailing Address - Country:US
Mailing Address - Phone:253-838-2620
Mailing Address - Fax:
Practice Address - Street 1:1411 SW DASH POINT RD
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-4524
Practice Address - Country:US
Practice Address - Phone:253-838-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor