Provider Demographics
NPI:1194840652
Name:WATT, TINA S (DC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:S
Last Name:WATT
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 1:2401 W TURNER RD
Mailing Address - Street 2:#230
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-334-2366
Mailing Address - Fax:209-334-2377
Practice Address - Street 1:2401 W TURNER RD
Practice Address - Street 2:#230
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-334-2366
Practice Address - Fax:209-334-2377
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23104111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
62797Medicare UPIN