Healthcare Provider Details

I. General information

NPI: 1134593221
Provider Name (Legal Business Name): TYLER FLAMMOND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 GRANT ST
CLARK SD
57225-1609
US

IV. Provider business mailing address

213 GRANT ST
CLARK SD
57225-1609
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax:
Mailing address:
  • Phone: 800-330-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293581
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1284829
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number092525
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH9194
License Number StateAL
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1838
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: