Provider Demographics
NPI:1265209423
Name:MILLER, TYLER JACOB
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JACOB
Last Name:MILLER
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 1:640 E HOLLYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3025
Mailing Address - Country:US
Mailing Address - Phone:208-870-4572
Mailing Address - Fax:
Practice Address - Street 1:1228 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1326
Practice Address - Country:US
Practice Address - Phone:801-883-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator