Healthcare Provider Details

I. General information

NPI: 1275479768
Provider Name (Legal Business Name): TYLER BRANTLEY KEITH GILE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CHARLOIS BLVD
WINSTON SALEM NC
27103-1588
US

IV. Provider business mailing address

1097 SALEM VILLAGE LN
CLEMMONS NC
27012-8972
US

V. Phone/Fax

Practice location:
  • Phone: 615-560-6622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: