Provider Demographics
NPI:1871999318
Name:TYSON, FREDA (DC)
Entity type:Individual
Prefix:DR
First Name:FREDA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 WINDING HILL RD
Mailing Address - Street 2:APT 213
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1346
Mailing Address - Country:US
Mailing Address - Phone:563-349-4652
Mailing Address - Fax:
Practice Address - Street 1:2435 KIMBERLY RD
Practice Address - Street 2:STE 30
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3509
Practice Address - Country:US
Practice Address - Phone:563-888-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5044-12111N00000X
IA077533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor