Provider Demographics
NPI:1609179217
Name:TIETSORT CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:TIETSORT CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIETSORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:509-775-3321
Mailing Address - Street 1:P.O. 577
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-0577
Mailing Address - Country:US
Mailing Address - Phone:509-775-3321
Mailing Address - Fax:509-775-3320
Practice Address - Street 1:28 NORTH KELLER STREET
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-0577
Practice Address - Country:US
Practice Address - Phone:509-775-3321
Practice Address - Fax:509-775-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1629108436Medicare UPIN