MEDICARE: MR. TYLER RICH LPN

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	163W00000X	Registered Nurse	185433-30	WI

General Provider Information

NPI Number	:	1134499585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER RICH LPN

Provider Business Mailing Address
First Line	:	1123 S CLEVELAND ST
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-3507
Country	:	US
Telephone Number	:	715-526-9691
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 S CLEVELAND ST
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-3507
Country	:	US
Telephone Number	:	715-526-9691
Fax Number	:

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

Provider Enumeration Date	:	01/03/2012
Last Update Date	:	01/27/2012

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Directions to “ MR. TYLER RICH LPN” Practice Location

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