Healthcare Provider Details

I. General information

NPI: 1104756170
Provider Name (Legal Business Name): BAILEY TYLER CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 CHERRY AVE APT 303
LONG BEACH CA
90813-2573
US

IV. Provider business mailing address

1742 CHERRY AVE APT 303
LONG BEACH CA
90813-2573
US

V. Phone/Fax

Practice location:
  • Phone: 316-293-6119
  • Fax:
Mailing address:
  • Phone: 316-293-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: