Provider Demographics
NPI:1245707157
Name:TYSON, CORINTHIAN ADOLPHOUS (DC)
Entity type:Individual
Prefix:DR
First Name:CORINTHIAN
Middle Name:ADOLPHOUS
Last Name:TYSON
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 1:7974 HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3052
Mailing Address - Country:US
Mailing Address - Phone:909-980-1985
Mailing Address - Fax:
Practice Address - Street 1:7974 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3052
Practice Address - Country:US
Practice Address - Phone:909-980-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34336111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA34336OtherCHIROPRACTIC LICENSE