Provider Demographics
NPI:1528458734
Name:DICKERSON, TANNER (DC)
Entity type:Individual
Prefix:DR
First Name:TANNER
Middle Name:
Last Name:DICKERSON
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 773
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-0773
Mailing Address - Country:US
Mailing Address - Phone:740-562-5600
Mailing Address - Fax:
Practice Address - Street 1:305 DOWNTOWNER PLZ
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1928
Practice Address - Country:US
Practice Address - Phone:740-562-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC.4491111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH152845874OtherTANNER DICKERSON NPI
OH1497147177OtherILLUME CHIROPRACTIC NPI