Provider Demographics
NPI:1386091031
Name:DRIEDRIC, TIM
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:DRIEDRIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 S BOWMAN RD APT 812
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4657
Mailing Address - Country:US
Mailing Address - Phone:501-351-4185
Mailing Address - Fax:
Practice Address - Street 1:3400 S. BOWMAN RD. APT 812
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211
Practice Address - Country:US
Practice Address - Phone:501-351-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer