Provider Demographics
NPI:1275517047
Name:THERIOT, TINA M (DC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:THERIOT
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 1:612 RUE DE ONETTA
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2163
Mailing Address - Country:US
Mailing Address - Phone:337-367-6649
Mailing Address - Fax:888-354-5793
Practice Address - Street 1:612 RUE DE ONETTA
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2163
Practice Address - Country:US
Practice Address - Phone:337-367-6649
Practice Address - Fax:888-354-5793
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U54350Medicare UPIN
LA5T645Medicare PIN