Provider Demographics
NPI:1760147508
Name:TYSDAL, JOHN (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TYSDAL
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 1:352 OLD GALLATIN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-8666
Mailing Address - Country:US
Mailing Address - Phone:270-237-3304
Mailing Address - Fax:
Practice Address - Street 1:501 HIGHWAY 52 BYP W
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-2636
Practice Address - Country:US
Practice Address - Phone:636-208-8163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor