Provider Demographics
NPI:1831217918
Name:POWELL, TRACEY (DC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:POWELL
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 1:932 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-1047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:932 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-1047
Practice Address - Country:US
Practice Address - Phone:765-675-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN811010Medicare ID - Type Unspecified
INU58444Medicare UPIN