Provider Demographics
NPI:1588659825
Name:HERGERT, TYCE D (DC)
Entity type:Individual
Prefix:DR
First Name:TYCE
Middle Name:D
Last Name:HERGERT
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 1:1500 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5950
Mailing Address - Country:US
Mailing Address - Phone:817-416-6116
Mailing Address - Fax:817-410-9411
Practice Address - Street 1:1500 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5950
Practice Address - Country:US
Practice Address - Phone:817-416-6116
Practice Address - Fax:817-410-9411
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:2006-03-29
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
TX7983111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU77863Medicare UPIN
TX00030ZMedicare ID - Type Unspecified