Provider Demographics
NPI:1497276745
Name:GARY TENNANT DC
Entity Type:Organization
Organization Name:GARY TENNANT DC
Other - Org Name:FUNCTIONAL MEDICINE VALPARAISO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-275-4698
Mailing Address - Street 1:2590 MORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6701
Mailing Address - Country:US
Mailing Address - Phone:219-232-9404
Mailing Address - Fax:219-293-8011
Practice Address - Street 1:2590 MORTHLAND DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-6701
Practice Address - Country:US
Practice Address - Phone:219-232-9404
Practice Address - Fax:219-293-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002905A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN08002905AOtherINDIANA LICENSE NUMBER