Healthcare Provider Details

I. General information

NPI: 1063059061
Provider Name (Legal Business Name): TYLER JAMES GREGURICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

IV. Provider business mailing address

9141 GRAND AVE
OMAHA NE
68134-2723
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax:
Mailing address:
  • Phone: 402-980-2485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: