Provider Demographics
NPI:1598971608
Name:POWELL, TYLER REED (DC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:REED
Last Name:POWELL
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 1:7575 W PEORIA AVE
Mailing Address - Street 2:SUITE A 106
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-5873
Mailing Address - Country:US
Mailing Address - Phone:623-873-4444
Mailing Address - Fax:623-979-8515
Practice Address - Street 1:7575 W PEORIA AVE
Practice Address - Street 2:SUITE A 106
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5873
Practice Address - Country:US
Practice Address - Phone:623-873-4444
Practice Address - Fax:623-979-8515
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ 0239560OtherBLUE CROSS
AZ2583988OtherAETNA
AZDC4767Medicare PIN
AZAZ 0239560OtherBLUE CROSS