Provider Demographics
NPI:1346019833
Name:THACKER, AUDREY (DC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:THACKER
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 1:1070 N RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-2004
Mailing Address - Country:US
Mailing Address - Phone:360-301-1437
Mailing Address - Fax:
Practice Address - Street 1:1070 N RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-2004
Practice Address - Country:US
Practice Address - Phone:360-301-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI-CHI-LIC-8701111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor