Healthcare Provider Details

I. General information

NPI: 1477243475
Provider Name (Legal Business Name): TYLER ROBERT SMITH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 PARK RD STE 104
CHARLOTTE NC
28203-6664
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 704-919-1280
  • Fax: 704-919-0580
Mailing address:
  • Phone: 423-541-5492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP22190
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: