Provider Demographics
NPI:1154616316
Name:THOMAS R WHITTY DC LLC
Entity type:Organization
Organization Name:THOMAS R WHITTY DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-532-5462
Mailing Address - Street 1:702 OWENS DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-3501
Mailing Address - Country:US
Mailing Address - Phone:417-532-5462
Mailing Address - Fax:417-532-8595
Practice Address - Street 1:702 OWENS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3501
Practice Address - Country:US
Practice Address - Phone:417-532-5462
Practice Address - Fax:417-532-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE004316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO752790204Medicaid
MO752790204Medicaid