Healthcare Provider Details

I. General information

NPI: 1689586620
Provider Name (Legal Business Name): TYLER ANTHONY SAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 US HIGHWAY 14A
POWELL WY
82435-9025
US

IV. Provider business mailing address

401 US HIGHWAY 14A
POWELL WY
82435-9025
US

V. Phone/Fax

Practice location:
  • Phone: 925-204-4003
  • Fax:
Mailing address:
  • Phone: 925-204-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number228409000
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: