Provider Demographics
NPI:1770613309
Name:TIMBERLAKE, LOTTA R (DC)
Entity type:Individual
Prefix:
First Name:LOTTA
Middle Name:R
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5452
Mailing Address - Country:US
Mailing Address - Phone:573-446-2242
Mailing Address - Fax:573-446-5575
Practice Address - Street 1:1511 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5452
Practice Address - Country:US
Practice Address - Phone:573-446-2242
Practice Address - Fax:573-446-5575
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE5196111NR0400X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000031359Medicare ID - Type Unspecified
MOT89005Medicare UPIN