Provider Demographics
NPI:1356006480
Name:FLAVIN, TYLER (CPO)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:FLAVIN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 BABCOCK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4411
Mailing Address - Country:US
Mailing Address - Phone:210-692-1111
Mailing Address - Fax:210-692-6041
Practice Address - Street 1:2122 BABCOCK RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4411
Practice Address - Country:US
Practice Address - Phone:210-692-1111
Practice Address - Fax:210-692-6041
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1858222Z00000X
TX101279332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist