Basic Information
| Provider Information | |||||||||
| NPI: | 1942690490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 HIGHWAY 49 S | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RICHLAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392189425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7692338844 | ||||||||
| FaxNumber: | 7692511825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HIGHWAY 49 S | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RICHLAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392189425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7692338844 | ||||||||
| FaxNumber: | 7692511825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2015 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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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 | 174400000X | OT2992 | MS | Y | Other Service Providers | Specialist |
No ID Information.