Provider Demographics
NPI:1780685255
Name:TESSENDORF, THOMAS N (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:N
Last Name:TESSENDORF
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 1:1401 W BIZTOWN LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5113
Mailing Address - Country:US
Mailing Address - Phone:208-762-3660
Mailing Address - Fax:208-762-3600
Practice Address - Street 1:1401 W BIZTOWN LOOP
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5113
Practice Address - Country:US
Practice Address - Phone:208-762-3660
Practice Address - Fax:208-762-3600
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2047111N00000X
IDCHIA-1564111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000075015OtherMEDICARE PTAN
T63492Medicare UPIN