Provider Demographics
NPI:1326131293
Name:PITMAN, TRISTA L (DC DICCP)
Entity Type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:L
Last Name:PITMAN
Suffix:
Gender:F
Credentials:DC DICCP
Other - Prefix:DR
Other - First Name:TRISTA
Other - Middle Name:LYNETTE
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:122 E EVERETT ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2140
Mailing Address - Country:US
Mailing Address - Phone:815-285-0611
Mailing Address - Fax:815-285-0124
Practice Address - Street 1:122 E EVERETT ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2140
Practice Address - Country:US
Practice Address - Phone:815-285-0611
Practice Address - Fax:815-285-0124
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
464537Medicare UPIN
IL630870Medicare ID - Type Unspecified
IL630870Medicare ID - Type Unspecified