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General NPI Number Information
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NPI Number | 1619348547
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Entity Type | Individual
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Provider Name | TYREL DETWEILER D.C.
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Gender | Male
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Dates
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Enumeration Date | 10/19/2015
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Last Update Date | 10/19/2015
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Provider Practice Location Address
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Address Line | 5740 GETWELL RD BLDG 4A
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City | SOUTHAVEN
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State | MS
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Zip | 38672-7361
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Country | US
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Telephone | 662-524-3200
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Fax |
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Provider Business Mailing Address
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Address Line | 463 MOCKINGBIRD LN
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2213
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Country | US
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Telephone | 319-400-9121
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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 | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 2894
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License Number State | TN
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