Provider Demographics
NPI:1831634542
Name:EDGE, MARK TYLER
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:TYLER
Last Name:EDGE
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 1:1229 DINAH SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37398-1135
Mailing Address - Country:US
Mailing Address - Phone:931-967-4199
Mailing Address - Fax:931-967-4099
Practice Address - Street 1:1229 DINAH SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-1135
Practice Address - Country:US
Practice Address - Phone:931-967-4199
Practice Address - Fax:931-967-4099
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor