Provider Demographics
NPI:1275118200
Name:TYLER, TEILA (OWNER)
Entity Type:Individual
Prefix:
First Name:TEILA
Middle Name:
Last Name:TYLER
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 FONTAINBLEAU DR
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4842
Mailing Address - Country:US
Mailing Address - Phone:770-407-9923
Mailing Address - Fax:
Practice Address - Street 1:2274 SALEM RD SE STE 106-1336
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2097
Practice Address - Country:US
Practice Address - Phone:770-407-9923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory