Provider Demographics
NPI:1962908004
Name:KINCHELOE, THOMAS LEWIS IV (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEWIS
Last Name:KINCHELOE
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8905 W GAGE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7191
Mailing Address - Country:US
Mailing Address - Phone:509-579-4300
Mailing Address - Fax:509-317-9542
Practice Address - Street 1:8905 W GAGE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7191
Practice Address - Country:US
Practice Address - Phone:509-579-4300
Practice Address - Fax:509-317-9542
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO202194204D00000X
390200000X
WAOP61377812204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program