Provider Demographics
NPI:1093773780
Name:REDENBAUGH, TIMOTHY WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:WILLIAM
Last Name:REDENBAUGH
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 1:712 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 ONEIDA ST
Practice Address - Street 2:SUITE B2
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3209
Practice Address - Country:US
Practice Address - Phone:712-732-3349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0176271Medicaid
IA0176271Medicaid