Provider Demographics
NPI:1386732337
Name:WARREN, TIMOTHY DALE (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DALE
Last Name:WARREN
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 1:1415 W 31ST ST S
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-2536
Mailing Address - Country:US
Mailing Address - Phone:316-529-3700
Mailing Address - Fax:316-529-0200
Practice Address - Street 1:1415 W 31ST ST S
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2536
Practice Address - Country:US
Practice Address - Phone:316-529-3700
Practice Address - Fax:316-529-0200
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
KS01-04242111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS59941OtherBLUE CROSS BLUE SHIELD
KS014153Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
KS59941OtherBLUE CROSS BLUE SHIELD