Healthcare Provider Details

I. General information

NPI: 1558797811
Provider Name (Legal Business Name): TYLER DUNHAM CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S. SHARON AMITY ROAD SUITE 104
CHARLOTTE NC
28211-2886
US

IV. Provider business mailing address

660 W LINCOLN HWY
EXTON PA
19341-2514
US

V. Phone/Fax

Practice location:
  • Phone: 704-372-7660
  • Fax: 704-372-7659
Mailing address:
  • Phone: 610-873-6733
  • Fax: 610-873-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: