Provider Demographics
NPI:1669972188
Name:VANDERWAL, TYLER JEFFREY (DC)
Entity type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JEFFREY
Last Name:VANDERWAL
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 1:2061 RIDGECREST RD SE APT 6
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4373
Mailing Address - Country:US
Mailing Address - Phone:616-350-7313
Mailing Address - Fax:
Practice Address - Street 1:649 EMMONS ST SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8316
Practice Address - Country:US
Practice Address - Phone:616-891-8153
Practice Address - Fax:616-891-8153
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010630111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor