Provider Demographics
NPI:1194701219
Name:DE LA TORRE, MICHELLE M (DC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:DE LA TORRE
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:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-0297
Mailing Address - Country:US
Mailing Address - Phone:573-468-4067
Mailing Address - Fax:
Practice Address - Street 1:433 W SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1545
Practice Address - Country:US
Practice Address - Phone:573-468-6011
Practice Address - Fax:573-468-7868
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU63347Medicare UPIN