Provider Demographics
NPI:1427145291
Name:TEEGERSTROM, TY L (DC)
Entity type:Individual
Prefix:DR
First Name:TY
Middle Name:L
Last Name:TEEGERSTROM
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 1:514 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUGOTON
Mailing Address - State:KS
Mailing Address - Zip Code:67951-2428
Mailing Address - Country:US
Mailing Address - Phone:620-544-7587
Mailing Address - Fax:620-544-7642
Practice Address - Street 1:514 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HUGOTON
Practice Address - State:KS
Practice Address - Zip Code:67951-2428
Practice Address - Country:US
Practice Address - Phone:620-544-7587
Practice Address - Fax:620-544-7642
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04552111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS059987Medicare ID - Type Unspecified