Provider Demographics
NPI:1154893717
Name:GRESS, TYLER (DC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GRESS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LEGACY PLZ W
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5285
Mailing Address - Country:US
Mailing Address - Phone:219-476-7246
Mailing Address - Fax:219-476-1713
Practice Address - Street 1:1928 45TH ST
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3917
Practice Address - Country:US
Practice Address - Phone:219-476-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013292111N00000X
IN08003084A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor