Healthcare Provider Details

I. General information

NPI: 1265110027
Provider Name (Legal Business Name): TYLER SCOTT FIDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 ROSCOE BLVD STE A1
VAN NUYS CA
91406-1246
US

IV. Provider business mailing address

304 N BRIGHTON ST
BURBANK CA
91506-2104
US

V. Phone/Fax

Practice location:
  • Phone: 442-681-8893
  • Fax:
Mailing address:
  • Phone: 661-342-4223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: