Provider Demographics
NPI:1376998047
Name:WALL, TIFFANY (DC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WALL
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 1:1215 MAIN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5987
Mailing Address - Country:US
Mailing Address - Phone:970-372-5101
Mailing Address - Fax:
Practice Address - Street 1:1215 MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5987
Practice Address - Country:US
Practice Address - Phone:970-372-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0007394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor