Provider Demographics
NPI:1689291635
Name:ANDERSON, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ANDERSON
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 1:2025 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-4590
Mailing Address - Country:US
Mailing Address - Phone:562-522-4529
Mailing Address - Fax:
Practice Address - Street 1:2025 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-4590
Practice Address - Country:US
Practice Address - Phone:562-522-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner