Healthcare Provider Details

I. General information

NPI: 1720311228
Provider Name (Legal Business Name): DR. TYLER T GATTEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 VALLEY FORGE AVE
FORT COLLINS CO
80526-1644
US

IV. Provider business mailing address

1713 VALLEY FORGE AVE
FORT COLLINS CO
80526-1644
US

V. Phone/Fax

Practice location:
  • Phone: 970-412-4675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number6294
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: