=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871132308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER JORDAN DEPAULIS DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2020
-----------------------------------------------------
Last Update Date | 07/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 HELMO AVE N
-----------------------------------------------------
City | OAKDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55128-6032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-797-2901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 HELMO AVE N
-----------------------------------------------------
City | OAKDALE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55128-6032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-797-2901
-----------------------------------------------------
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 | 6680
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------