Provider Demographics
NPI:1518261791
Name:THAO, POUA (DC)
Entity Type:Individual
Prefix:
First Name:POUA
Middle Name:
Last Name:THAO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6798 HADLEY AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-1073
Mailing Address - Country:US
Mailing Address - Phone:651-621-2206
Mailing Address - Fax:651-578-8587
Practice Address - Street 1:964 INWOOD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6625
Practice Address - Country:US
Practice Address - Phone:651-621-2206
Practice Address - Fax:651-578-8587
Is Sole Proprietor?:No
Enumeration Date:2011-01-03
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5474111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor