Provider Demographics
NPI:1508873746
Name:LEE, TYLER (PT)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 MARTIN LUTHER KING JR AVE SW
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2605
Practice Address - Country:US
Practice Address - Phone:229-377-0882
Practice Address - Fax:229-377-0883
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116558OtherMEDICARE