Basic Information
| Provider Information | |||||||||
| NPI: | 1134447519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | ROSS | ||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505118 | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186929640 | ||||||||
| FaxNumber: | 6186929643 | ||||||||
| Practice Location | |||||||||
| Address1: | 3986 MARYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620404191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187970618 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2010 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 038011680 | IL | Y | Chiropractic Providers | Chiropractor |
No ID Information.