Provider Demographics
NPI:1881657575
Name:TIETSORT, SARAH PATRICE (DC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:PATRICE
Last Name:TIETSORT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:PATRICE
Other - Last Name:DINGMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2549 JOLLY RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3678
Mailing Address - Country:US
Mailing Address - Phone:517-347-2222
Mailing Address - Fax:517-347-2233
Practice Address - Street 1:2549 JOLLY RD
Practice Address - Street 2:SUITE 360
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3678
Practice Address - Country:US
Practice Address - Phone:517-347-2222
Practice Address - Fax:517-347-2233
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI44-00208OtherPHP OF MICHIGAN
MI44-00208OtherPHP OF MICHIGAN