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General NPI Number Information
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NPI Number | 1578149266
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Entity Type | Individual
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Provider Name | TYLER BOYACK OD
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Gender | Male
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Dates
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Enumeration Date | 03/22/2021
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Last Update Date | 08/19/2021
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Provider Practice Location Address
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Address Line | 825 S 20TH AVE
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City | SAFFORD
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State | AZ
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Zip | 85546-3317
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Country | US
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Telephone | 928-428-6930
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Fax | 602-508-4830
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Provider Business Mailing Address
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Address Line | 4800 N 22ND ST STE 210
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City | PHOENIX
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State | AZ
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Zip | 85016-4963
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Country | US
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Telephone | 602-955-1000
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Fax | 602-508-4830
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT-002496
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License Number State | AZ
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