=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376306969
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE KOLTYN THOMAS DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2024
-----------------------------------------------------
Last Update Date | 02/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905A S ODELL AVE
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65340-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-631-9933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905A S ODELL AVE
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65340-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-631-9933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2023002858
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------