Provider Demographics
NPI:1205501558
Name:SANDSTROM, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SANDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5804 E GOVERNOR JOHN SEVIER HWY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-3605
Mailing Address - Country:US
Mailing Address - Phone:865-951-2811
Mailing Address - Fax:
Practice Address - Street 1:5804 E GOVERNOR JOHN SEVIER HWY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-3605
Practice Address - Country:US
Practice Address - Phone:865-951-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor