Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 12018 | TX |
Y | 111NR0400X | Rehabilitation Chiropractor | 12018 | TX |
NPI | 1316201619 |
---|---|
Provider Name | Dr. Stephen Ray Tietjen |
First Address | North Richland Hills, TX 76180 |
Second Address | North Richland Hills, TX 76180-6558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2012 |
Last Update Date | 02/07/2012 |