Provider Demographics
NPI:1477844215
Name:HORNER, TYRA B (DC)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:B
Last Name:HORNER
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 1:625 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2718
Mailing Address - Country:US
Mailing Address - Phone:630-818-6775
Mailing Address - Fax:
Practice Address - Street 1:24014 W RENWICK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-8708
Practice Address - Country:US
Practice Address - Phone:815-417-5777
Practice Address - Fax:815-531-0473
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011899111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor