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General NPI Number Information
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NPI Number | 1932591120
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Entity Type | Individual
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Provider Name | TYLER JORDAN PHILLIPS ATC
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Gender | Male
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Dates
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Enumeration Date | 02/24/2015
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Last Update Date | 02/24/2015
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Provider Practice Location Address
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Address Line | 100 E UNIVERSITY # 9522
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City | MAGNOLIA
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State | AR
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Zip | 71753-2181
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Country | US
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Telephone | 501-467-5349
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Fax |
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Provider Business Mailing Address
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Address Line | 2909 HIGHWAY 229 N
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City | TRASKWOOD
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State | AR
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Zip | 72167-9181
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Country | US
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Telephone | 501-467-5349
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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