Provider Demographics
NPI:1134447519
Name:TYLER, ROSS (DC)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:TYLER
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:PO BOX 505118
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5118
Mailing Address - Country:US
Mailing Address - Phone:618-692-9640
Mailing Address - Fax:618-692-9643
Practice Address - Street 1:3986 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4191
Practice Address - Country:US
Practice Address - Phone:618-797-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011680111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor