Provider Demographics
NPI:1861866634
Name:WILT, TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:WILT
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 1:331 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-2205
Mailing Address - Country:US
Mailing Address - Phone:570-765-0965
Mailing Address - Fax:
Practice Address - Street 1:333 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2205
Practice Address - Country:US
Practice Address - Phone:570-368-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor