Provider Demographics
NPI:1558436170
Name:REISECK, TIMOTHY ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:REISECK
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 1:2254 FLOYD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9602
Mailing Address - Country:US
Mailing Address - Phone:209-551-7731
Mailing Address - Fax:209-551-7740
Practice Address - Street 1:2254 FLOYD AVE STE B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9602
Practice Address - Country:US
Practice Address - Phone:209-551-7731
Practice Address - Fax:209-551-7740
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 25373111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 0253730Medicare ID - Type Unspecified
CADC 0253730Medicare UPIN