MEDICARE: JUSTIN TYLER PT, DPT

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	225100000X	Physical Therapist	PT015685	GA

General Provider Information

NPI Number	:	1932911963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN TYLER PT, DPT

Provider Business Mailing Address
First Line	:	5380 GLADE PARK DR
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2572
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4024 LAWRENCEVILLE HWY NW STE 19&20
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2999
Country	:	US
Telephone Number	:	770-931-8686
Fax Number	:

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

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	02/03/2025

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