Provider Demographics
NPI:1548202591
Name:DEWALL, THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:DEWALL
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 1:804 FREEPORT AVE NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2632
Mailing Address - Country:US
Mailing Address - Phone:763-441-0644
Mailing Address - Fax:763-441-4263
Practice Address - Street 1:804 FREEPORT AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2632
Practice Address - Country:US
Practice Address - Phone:763-441-0644
Practice Address - Fax:763-441-4263
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350003623Medicare ID - Type UnspecifiedMEDICARE