Provider Demographics
NPI:1710950118
Name:TICE, JOHN D (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:TICE
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 1:1211 HWY 133 NORTH
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635
Mailing Address - Country:US
Mailing Address - Phone:870-364-9540
Mailing Address - Fax:870-364-9840
Practice Address - Street 1:1211 HWY 133 NORTH
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635
Practice Address - Country:US
Practice Address - Phone:870-364-9540
Practice Address - Fax:870-364-9840
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1461111N00000X
LA1148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133792718Medicaid
57685OtherGROUP NUMBER
57685OtherGROUP NUMBER
U66258Medicare UPIN