Provider Demographics
NPI:1295750131
Name:TESSEREAU, ERIC JON (DC)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:TESSEREAU
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 1494
Mailing Address - Street 2:430 GODDARD AVENUE
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-1494
Mailing Address - Country:US
Mailing Address - Phone:970-563-0330
Mailing Address - Fax:970-563-0331
Practice Address - Street 1:430 GODDARD AVE.
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-1494
Practice Address - Country:US
Practice Address - Phone:970-563-0330
Practice Address - Fax:970-563-0331
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU-46224Medicare UPIN
CO800795Medicare ID - Type Unspecified