Healthcare Provider Details

I. General information

NPI: 1063206340
Provider Name (Legal Business Name): TYSON LAUDERDALE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E STATE ST STE D
ATHENS OH
45701-1870
US

IV. Provider business mailing address

72 N HURON AVE
COLUMBUS OH
43204-2661
US

V. Phone/Fax

Practice location:
  • Phone: 740-326-6110
  • Fax:
Mailing address:
  • Phone: 614-984-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: