Provider Demographics
NPI:1750830345
Name:REIDHEAD, TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:REIDHEAD
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 1:5220 N HICKORY GLEN PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2491
Mailing Address - Country:US
Mailing Address - Phone:801-857-0301
Mailing Address - Fax:
Practice Address - Street 1:337 DEINHARD LN
Practice Address - Street 2:STE A
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4703
Practice Address - Country:US
Practice Address - Phone:801-857-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-24
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor