MEDICARE: TYLER KING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1114426558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER KING

Provider Business Mailing Address
First Line	:	281 W LINDEN DR
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-5010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	281 W LINDEN DR
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-5010
Country	:	US
Telephone Number	:	805-551-2086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2018
Last Update Date	:	02/11/2018

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Directions to “ TYLER KING ” Practice Location

Language	Start Address	Practice Location

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