Provider Demographics
NPI:1053411801
Name:TOLLSTRUP, TYLER (DC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TOLLSTRUP
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 1:560 MASONIC WAY
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2703
Mailing Address - Country:US
Mailing Address - Phone:650-598-0200
Mailing Address - Fax:650-598-9165
Practice Address - Street 1:560 MASONIC WAY
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2703
Practice Address - Country:US
Practice Address - Phone:650-598-0200
Practice Address - Fax:650-598-9165
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU 04820Medicare UPIN
CA0125600Medicare ID - Type Unspecified