Healthcare Provider Details

I. General information

NPI: 1518538651
Provider Name (Legal Business Name): TYLER DEGOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

3950 MAYFIELD AVE NE APT 2F
GRAND RAPIDS MI
49525-6610
US

V. Phone/Fax

Practice location:
  • Phone: 855-407-7575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: