Provider Demographics
NPI:1881810828
Name:THATCHER, THEODORE JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JOHN
Last Name:THATCHER
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 1:53029 PINE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-9790
Mailing Address - Country:US
Mailing Address - Phone:574-848-7711
Mailing Address - Fax:574-264-1901
Practice Address - Street 1:3120 WINDSOR CT
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5556
Practice Address - Country:US
Practice Address - Phone:574-264-3344
Practice Address - Fax:574-264-1901
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001506A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092878OtherANTHEM BLUE CROSS BLUE SH
IN168690Medicare ID - Type Unspecified