Provider Demographics
NPI:1215396874
Name:THACKER, TOBE (DC)
Entity Type:Individual
Prefix:
First Name:TOBE
Middle Name:
Last Name:THACKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 S PARK DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5724
Mailing Address - Country:US
Mailing Address - Phone:580-584-3385
Mailing Address - Fax:580-584-5454
Practice Address - Street 1:1605 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5724
Practice Address - Country:US
Practice Address - Phone:580-584-3385
Practice Address - Fax:580-584-5454
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4336111N00000X
IDCHIA-1704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty