Provider Demographics
NPI:1316023914
Name:WHITTENBURG, TARESA MAE (DC)
Entity Type:Individual
Prefix:DR
First Name:TARESA
Middle Name:MAE
Last Name:WHITTENBURG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TARESA
Other - Middle Name:MAE
Other - Last Name:JOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1012 CARVER ROAD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-549-2215
Mailing Address - Fax:209-549-2216
Practice Address - Street 1:1012 CARVER ROAD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-549-2215
Practice Address - Fax:209-549-2216
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
20036OtherCA LIC
CABDC000520Medicaid
CABDC000520Medicaid
4169993Medicare UPIN