=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487182960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. TYLER MARK LY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5430 POLAR BEAR CT NE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-260-8194
-----------------------------------------------------
Fax | 616-883-6531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5430 POLAR BEAR CT NE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-260-8194
-----------------------------------------------------
Fax | 616-883-6531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | AF410343519
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------