Healthcare Provider Details

I. General information

NPI: 1861355000
Provider Name (Legal Business Name): TYLER SCOTT SIPES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4184 BEAM RD
CRESTLINE OH
44827-9640
US

IV. Provider business mailing address

4184 BEAM RD
CRESTLINE OH
44827-9640
US

V. Phone/Fax

Practice location:
  • Phone: 419-632-5693
  • Fax:
Mailing address:
  • Phone: 419-632-5693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT006350
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: