=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841859261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER BIGENHO DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2019
-----------------------------------------------------
Last Update Date | 09/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4121 WESTERLY PL STE 115
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-227-1125
-----------------------------------------------------
Fax | 949-209-0349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9611 CLEARBROOK DR
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92646-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-227-1125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 34563
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------