Provider Demographics
NPI:1477724813
Name:THEOBALD, PATRICK JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JAY
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 SPUR DR
Mailing Address - Street 2:STE 220
Mailing Address - City:MARSHFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65706-2344
Mailing Address - Country:US
Mailing Address - Phone:417-859-7750
Mailing Address - Fax:417-859-6541
Practice Address - Street 1:1350 SPUR DR
Practice Address - Street 2:STE 220
Practice Address - City:MARSHFIELD
Practice Address - State:MO
Practice Address - Zip Code:65706-2344
Practice Address - Country:US
Practice Address - Phone:417-859-7750
Practice Address - Fax:417-859-6541
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor