Provider Demographics
NPI:1518189406
Name:DIFEDELE, THOMAS R (LMBT, DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:DIFEDELE
Suffix:
Gender:M
Credentials:LMBT, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 THAMES DR.
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687
Mailing Address - Country:US
Mailing Address - Phone:864-233-2221
Mailing Address - Fax:
Practice Address - Street 1:1310 E. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-233-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor