Provider Demographics
NPI:1003045295
Name:TEDRICK, TARA (DC)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:TEDRICK
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 1:970 N KALAHEO AVE STE C315
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1883
Mailing Address - Country:US
Mailing Address - Phone:808-254-5577
Mailing Address - Fax:
Practice Address - Street 1:970 N. KALAHEO AVENUE
Practice Address - Street 2:C315
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-254-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1326111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor