Provider Demographics
NPI:1447912548
Name:GRAHAM, TYLER MAITLAND
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:MAITLAND
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-3574
Mailing Address - Country:US
Mailing Address - Phone:574-274-8960
Mailing Address - Fax:765-662-0101
Practice Address - Street 1:2716 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-3574
Practice Address - Country:US
Practice Address - Phone:574-274-8960
Practice Address - Fax:765-662-0101
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003233A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor