Healthcare Provider Details

I. General information

NPI: 1275096893
Provider Name (Legal Business Name): TYRELL SELLERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 MICHAEL CT APT 4
ANCHORAGE AK
99504-1235
US

IV. Provider business mailing address

148 MICHAEL CT APT 4
ANCHORAGE AK
99504-1235
US

V. Phone/Fax

Practice location:
  • Phone: 907-885-9026
  • Fax:
Mailing address:
  • Phone: 907-885-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15338
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: