Healthcare Provider Details

I. General information

NPI: 1205750254
Provider Name (Legal Business Name): TYMIR HAMMOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BOWMAN ST
MANSFIELD OH
44903-1235
US

IV. Provider business mailing address

400 BOWMAN ST
MANSFIELD OH
44903-1235
US

V. Phone/Fax

Practice location:
  • Phone: 567-307-9194
  • Fax: 567-307-9194
Mailing address:
  • Phone: 419-525-3525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA164956
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: