Provider Demographics
NPI:1710157144
Name:FEDDES, TARA (DC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FEDDES
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 1:200 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-1108
Mailing Address - Country:US
Mailing Address - Phone:618-395-9131
Mailing Address - Fax:618-395-9131
Practice Address - Street 1:200 N WEST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-1108
Practice Address - Country:US
Practice Address - Phone:618-395-9131
Practice Address - Fax:618-395-9131
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009438111N00000X
IL038012468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4935415Medicaid
MI950F325610OtherB/C B/S
MIOP21270Medicare PIN