Provider Demographics
NPI:1043827819
Name:SODERQVIST, IAN (DC)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:SODERQVIST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14902 TRINITY RIVER DR STE 2
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-5750
Mailing Address - Country:US
Mailing Address - Phone:361-654-4747
Mailing Address - Fax:361-654-4750
Practice Address - Street 1:14902 TRINITY RIVER DR STE 2
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-5750
Practice Address - Country:US
Practice Address - Phone:361-654-4747
Practice Address - Fax:361-654-4750
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor