Provider Demographics
NPI:1629108436
Name:TIETSORT, STEVEN GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:GEORGE
Last Name:TIETSORT
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:PO BOX 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 N 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
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000301615Medicare ID - Type Unspecified