Provider Demographics
NPI:1336236827
Name:STACKIS, TIMOTHY MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:STACKIS
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 1:2454 MEINEN CT
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002
Mailing Address - Country:US
Mailing Address - Phone:563-582-0300
Mailing Address - Fax:
Practice Address - Street 1:2454 MEINEN CT
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002
Practice Address - Country:US
Practice Address - Phone:563-582-0300
Practice Address - Fax:563-582-6990
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0469346Medicaid
IAI15414Medicare ID - Type Unspecified