Provider Demographics
NPI:1700024155
Name:TYER, KEVIN (DPT)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:TYER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132B SUNSET CT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-2429
Mailing Address - Country:US
Mailing Address - Phone:803-796-5116
Mailing Address - Fax:803-796-5131
Practice Address - Street 1:132 SUNSET CT
Practice Address - Street 2:SUITE B
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-2429
Practice Address - Country:US
Practice Address - Phone:803-796-5116
Practice Address - Fax:803-796-5131
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5901174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8644Medicare PIN