Healthcare Provider Details

I. General information

NPI: 1780685255
Provider Name (Legal Business Name): THOMAS N TESSENDORF DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W BIZTOWN LOOP
HAYDEN ID
83835-5113
US

IV. Provider business mailing address

1401 W BIZTOWN LOOP
HAYDEN ID
83835-5113
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-3660
  • Fax: 208-762-3600
Mailing address:
  • Phone: 208-762-3660
  • Fax: 208-762-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2047
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1564
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: