Healthcare Provider Details

I. General information

NPI: 1629576863
Provider Name (Legal Business Name): TRISTAN DANIEL PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 30TH ST NE
CANTON OH
44714-1404
US

IV. Provider business mailing address

807 30TH ST NE
CANTON OH
44714-1404
US

V. Phone/Fax

Practice location:
  • Phone: 330-491-0381
  • Fax:
Mailing address:
  • Phone: 330-491-0381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-05377
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: