Healthcare Provider Details

I. General information

NPI: 1790490605
Provider Name (Legal Business Name): TYLER BROOKINGS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MAIN AVE STE 107
GRESHAM OR
97030-7264
US

IV. Provider business mailing address

10100 SW LANCASTER RD
PORTLAND OR
97219-6303
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-8495
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6279
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: