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General NPI Number Information
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NPI Number | 1104808435
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Entity Type | Individual
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Provider Name | TJODE M MICKELSON D.C
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Gender | Female
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Dates
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Enumeration Date | 11/14/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 105 BORGA BUILDING
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City | FESTUS
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State | MO
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Zip | 63028-1136
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Country | US
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Telephone | 636-937-3207
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Fax | 636-937-5307
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Provider Business Mailing Address
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Address Line | 8914 KATHLYN DR
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City | SAINT LOUIS
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State | MO
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Zip | 63134-3552
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Country | US
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Telephone | 314-398-5800
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2005036767
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License Number State | MO
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