Provider Demographics
NPI:1932591120
Name:PHILLIPS, TYLER JORDAN (ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JORDAN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 HIGHWAY 229 N
Mailing Address - Street 2:
Mailing Address - City:TRASKWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72167-9181
Mailing Address - Country:US
Mailing Address - Phone:501-467-5349
Mailing Address - Fax:
Practice Address - Street 1:100 E UNIVERSITY # 9522
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2181
Practice Address - Country:US
Practice Address - Phone:501-467-5349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer