Healthcare Provider Details

I. General information

NPI: 1053841585
Provider Name (Legal Business Name): TYLER LEE HULS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SGT PRENTISS DRIVE
NATCHEZ MS
39120
US

IV. Provider business mailing address

1114 PALM ST
VIDALIA LA
71373-3847
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-9654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0816
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: