Provider Demographics
NPI:1619348547
Name:DETWEILER, TYREL (DC)
Entity Type:Individual
Prefix:DR
First Name:TYREL
Middle Name:
Last Name:DETWEILER
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 1:463 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2213
Mailing Address - Country:US
Mailing Address - Phone:319-400-9121
Mailing Address - Fax:
Practice Address - Street 1:5740 GETWELL RD BLDG 4A
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7361
Practice Address - Country:US
Practice Address - Phone:662-524-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2894111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician