Healthcare Provider Details

I. General information

NPI: 1174443030
Provider Name (Legal Business Name): TYLER MINNICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 E COLISEUM BLVD
FORT WAYNE IN
46805-1445
US

IV. Provider business mailing address

15635 FEIGHNER RD
ROANOKE IN
46783-8701
US

V. Phone/Fax

Practice location:
  • Phone: 260-257-6831
  • Fax:
Mailing address:
  • Phone: 260-530-6630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: