Healthcare Provider Details

I. General information

NPI: 1134524820
Provider Name (Legal Business Name): TYLER OWENS PTA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 OLLIE AVE
CLANTON AL
35045-2246
US

IV. Provider business mailing address

674 OLLIE AVE
CLANTON AL
35045-2246
US

V. Phone/Fax

Practice location:
  • Phone: 205-280-1100
  • Fax: 205-280-1575
Mailing address:
  • Phone:
  • Fax: 205-280-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number11915
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1503
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: