Healthcare Provider Details

I. General information

NPI: 1174315162
Provider Name (Legal Business Name): TYLER B SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 W GUADALUPE RD STE 19
MESA AZ
85202-7245
US

IV. Provider business mailing address

2655 W GUADALUPE RD STE 19
MESA AZ
85202-7245
US

V. Phone/Fax

Practice location:
  • Phone: 210-412-3439
  • Fax:
Mailing address:
  • Phone: 210-412-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: