Provider Demographics
NPI:1134286685
Name:RICHARDS, TYLER MARK (DC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:MARK
Last Name:RICHARDS
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 1:421 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07704-3029
Mailing Address - Country:US
Mailing Address - Phone:732-758-9210
Mailing Address - Fax:
Practice Address - Street 1:236 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6630
Practice Address - Country:US
Practice Address - Phone:732-229-1649
Practice Address - Fax:732-229-5176
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00557700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8286108Medicaid
NJ6462620001OtherPTAN
NJ8286108Medicaid