Provider Demographics
NPI:1366648560
Name:REAVIS, TANIA EVON (DC)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:EVON
Last Name:REAVIS
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 1:1200 E WOODHURST DR
Mailing Address - Street 2:R300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4261
Mailing Address - Country:US
Mailing Address - Phone:417-877-1300
Mailing Address - Fax:
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:R300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4261
Practice Address - Country:US
Practice Address - Phone:417-877-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003027886111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000026126Medicare PIN