Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 2000166831 | MO |
NPI | 1366645038 |
---|---|
Provider Name | Dr. John Telfer Tweedie III |
First Address | Bolivar, MO 65613-1519 |
Second Address | Bolivar, MO 65613-1519 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2007 |
Last Update Date | 15/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
319264855 | (02) | MO |