Provider Demographics
NPI:1316334733
Name:MELNICOVE, TYLER DEAN (ATC, EMT)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:DEAN
Last Name:MELNICOVE
Suffix:
Gender:M
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:PITTSGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-9177
Mailing Address - Country:US
Mailing Address - Phone:609-805-4695
Mailing Address - Fax:
Practice Address - Street 1:1132 RAINBOW CIR
Practice Address - Street 2:
Practice Address - City:PITTSGROVE
Practice Address - State:NJ
Practice Address - Zip Code:08318-9177
Practice Address - Country:US
Practice Address - Phone:609-805-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ20000254372255A2300X
NJ608409146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic