Healthcare Provider Details

I. General information

NPI: 1558436170
Provider Name (Legal Business Name): TIMOTHY ROBERT REISECK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2254 FLOYD AVE STE B
MODESTO CA
95355-9602
US

IV. Provider business mailing address

2254 FLOYD AVE STE B
MODESTO CA
95355-9602
US

V. Phone/Fax

Practice location:
  • Phone: 209-551-7731
  • Fax: 209-551-7740
Mailing address:
  • Phone: 209-551-7731
  • Fax: 209-551-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 25373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: