Provider Demographics
NPI:1871952481
Name:TOBE THACKER
Entity type:Organization
Organization Name:TOBE THACKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOBE
Authorized Official - Middle Name:
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-584-3385
Mailing Address - Street 1:1605 S PARK DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5724
Mailing Address - Country:US
Mailing Address - Phone:580-584-3385
Mailing Address - Fax:
Practice Address - Street 1:1605 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5724
Practice Address - Country:US
Practice Address - Phone:580-584-3385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20008808Medicare PIN