Provider Demographics
NPI:1124131099
Name:PALIC, THOMAS JEROME (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JEROME
Last Name:PALIC
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 2812
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632
Mailing Address - Country:US
Mailing Address - Phone:970-766-7100
Mailing Address - Fax:970-766-7101
Practice Address - Street 1:210 EDWARDS VILLAGE BLVD
Practice Address - Street 2:UNIT A101
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-766-7100
Practice Address - Fax:970-766-7101
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION27510Medicare UPIN