Provider Demographics
NPI:1508826942
Name:TL-JST, INC.
Entity Type:Organization
Organization Name:TL-JST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, DC
Authorized Official - Phone:563-359-1702
Mailing Address - Street 1:1750 PRAIRIE VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1828
Mailing Address - Country:US
Mailing Address - Phone:563-359-1702
Mailing Address - Fax:
Practice Address - Street 1:1750 PRAIRIE VISTA CIR
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1828
Practice Address - Country:US
Practice Address - Phone:563-359-1702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5695111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11784OtherBLUE CROSS / BLUE SHIELD
IAI12174Medicare ID - Type UnspecifiedCHIROPRACTIC
IAU42064Medicare UPIN