Provider Demographics
NPI:1487182960
Name:LY, TYLER MARK
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:MARK
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 POLAR BEAR CT NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7517
Mailing Address - Country:US
Mailing Address - Phone:616-260-8194
Mailing Address - Fax:616-883-6531
Practice Address - Street 1:5430 POLAR BEAR CT NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7517
Practice Address - Country:US
Practice Address - Phone:616-260-8194
Practice Address - Fax:616-883-6531
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410343519311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home