Provider Demographics
NPI:1770661647
Name:MINCEY, TYRAN G (DC)
Entity Type:Individual
Prefix:DR
First Name:TYRAN
Middle Name:G
Last Name:MINCEY
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 1:295 BLOOMFIELD AVE
Mailing Address - Street 2:COMMERCIAL UNIT #5
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3643
Mailing Address - Country:US
Mailing Address - Phone:973-744-1155
Mailing Address - Fax:973-744-5511
Practice Address - Street 1:295 BLOOMFIELD AVE
Practice Address - Street 2:COMMERCIAL UNIT #1
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3643
Practice Address - Country:US
Practice Address - Phone:973-744-1155
Practice Address - Fax:973-744-5511
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00543600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ034637Medicare ID - Type Unspecified