Healthcare Provider Details

I. General information

NPI: 1811670995
Provider Name (Legal Business Name): TYLER BRIDGES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N HILL AVE
PASADENA CA
91104-2616
US

IV. Provider business mailing address

1500 N HILL AVE
PASADENA CA
91104-2616
US

V. Phone/Fax

Practice location:
  • Phone: 530-227-9513
  • Fax:
Mailing address:
  • Phone: 530-227-9513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: