Provider Demographics
NPI:1205426327
Name:CLARK, TYLER (CHIROPRACTOR)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 REMINGTON AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3603
Mailing Address - Country:US
Mailing Address - Phone:315-714-2033
Mailing Address - Fax:
Practice Address - Street 1:3 REMINGTON AVE SUITE 5
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3722
Practice Address - Country:US
Practice Address - Phone:315-714-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013335-01111N00000X
NY013335-01111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor