Healthcare Provider Details

I. General information

NPI: 1144605098
Provider Name (Legal Business Name): TYLER STOLTMAN ACT/LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 E 39TH ST S STE 230
INDEPENDENCE MO
64057-2309
US

IV. Provider business mailing address

19550 E 39TH ST S STE 230
INDEPENDENCE MO
64057-2309
US

V. Phone/Fax

Practice location:
  • Phone: 816-795-8200
  • Fax: 816-795-7735
Mailing address:
  • Phone: 816-795-8200
  • Fax: 816-795-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2013028788
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: