Healthcare Provider Details

I. General information

NPI: 1639543374
Provider Name (Legal Business Name): TYLER ALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4267 MONROE ST
ECORSE MI
48229-1519
US

IV. Provider business mailing address

4267 MONROE ST
ECORSE MI
48229-1519
US

V. Phone/Fax

Practice location:
  • Phone: 313-236-2881
  • Fax:
Mailing address:
  • Phone: 313-236-2881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number121773384
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: