Provider Demographics
NPI:1790770485
Name:TENNANT, ROBERT WYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WYNNE
Last Name:TENNANT
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 1:1471 JASON RD
Mailing Address - Street 2:STE 100
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-1097
Mailing Address - Country:US
Mailing Address - Phone:765-737-1117
Mailing Address - Fax:765-737-1119
Practice Address - Street 1:1471 JASON RD
Practice Address - Street 2:STE 100
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1097
Practice Address - Country:US
Practice Address - Phone:765-737-1117
Practice Address - Fax:765-737-1119
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-19
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN492111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000096713OtherANTHEM
IN100127340AMedicaid
320670Medicare ID - Type Unspecified
IN100127340AMedicaid