1720031818 NPI number — DR. TONY CLARK JENSEN CHIROPRACTOR

Table of content: DR. TONY CLARK JENSEN CHIROPRACTOR (NPI 1720031818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720031818 NPI number — DR. TONY CLARK JENSEN CHIROPRACTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
TONY
Provider Middle Name:
CLARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
CHIROPRACTOR
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720031818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 W MOANA LN
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89509-4902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-323-1222
Provider Business Mailing Address Fax Number:
775-323-7002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 W MOANA LN
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89509-4902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-323-1222
Provider Business Practice Location Address Fax Number:
775-323-7002
Provider Enumeration Date:
05/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  B00576 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: DC23163 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)