Healthcare Provider Details

I. General information

NPI: 1427726744
Provider Name (Legal Business Name): TYLER JACKSON KOLZOW PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7119 E BROADWAY BLVD
TUCSON AZ
85710-1404
US

IV. Provider business mailing address

2469 GREEN VALLEY CT
AURORA IL
60503-5756
US

V. Phone/Fax

Practice location:
  • Phone: 520-881-0050
  • Fax:
Mailing address:
  • Phone: 630-864-7926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberLPT-31924
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: