Healthcare Provider Details

I. General information

NPI: 1033157730
Provider Name (Legal Business Name): JASON RANDALL THORNLEY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S STERLING AVE A
SUGAR CREEK MO
64054-1558
US

IV. Provider business mailing address

410 S STERLING AVE A
SUGAR CREEK MO
64054-1558
US

V. Phone/Fax

Practice location:
  • Phone: 816-461-3040
  • Fax: 816-461-3040
Mailing address:
  • Phone: 816-461-3040
  • Fax: 816-461-3040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2004035757
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: