Provider Demographics
NPI:1518949031
Name:HALLER, JOHN THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:HALLER
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 1:105 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-0957
Mailing Address - Country:US
Mailing Address - Phone:816-625-4580
Mailing Address - Fax:816-625-4580
Practice Address - Street 1:105 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075-0957
Practice Address - Country:US
Practice Address - Phone:816-625-4580
Practice Address - Fax:816-625-4580
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0008732Medicare ID - Type Unspecified