Provider Demographics
NPI:1518387117
Name:VANGEMERT, TYLER (LAC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VANGEMERT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 MAIN AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1315 MAIN AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5173
Practice Address - Country:US
Practice Address - Phone:970-247-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1400171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist