Provider Demographics
NPI:1356127690
Name:VIRDEN, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VIRDEN
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 1:9320 E SERPENTINE LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-7562
Mailing Address - Country:US
Mailing Address - Phone:832-967-7419
Mailing Address - Fax:
Practice Address - Street 1:8200 E JACQUE DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-6172
Practice Address - Country:US
Practice Address - Phone:928-277-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty