Healthcare Provider Details

I. General information

NPI: 1366971301
Provider Name (Legal Business Name): TYLER TIMOTHY TRIGGS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NE SAINT LUKES BLVD STE 200
LEES SUMMIT MO
64086-6011
US

IV. Provider business mailing address

1230 MISSOURI CT APT 321
LIBERTY MO
64068-2674
US

V. Phone/Fax

Practice location:
  • Phone: 816-246-4302
  • Fax:
Mailing address:
  • Phone: 417-689-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: