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General NPI Number Information
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NPI Number | 1316334733
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Entity Type | Individual
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Provider Name | TYLER DEAN MELNICOVE ATC, EMT
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Gender | Male
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Dates
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Enumeration Date | 04/23/2015
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Last Update Date | 09/19/2016
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Provider Practice Location Address
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Address Line | 1132 RAINBOW CIR
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City | PITTSGROVE
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State | NJ
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Zip | 08318-9177
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Country | US
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Telephone | 609-805-4695
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Fax |
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Provider Business Mailing Address
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Address Line | 1132 RAINBOW CIR
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City | PITTSGROVE
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State | NJ
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Zip | 08318-9177
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Country | US
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Telephone | 609-805-4695
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000025437
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 146N00000X
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Taxonomy Name | Basic Emergency Medical Technician
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License Number | 608409
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License Number State | NJ
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