1023240587 NPI number — MS. TINA M. DAVIS-LARKIN APN

Table of content: MS. TINA M. DAVIS-LARKIN APN (NPI 1023240587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023240587 NPI number — MS. TINA M. DAVIS-LARKIN APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS-LARKIN
Provider First Name:
TINA
Provider Middle Name:
M.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023240587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8043 S FAIRFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60652-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-684-4116
Provider Business Mailing Address Fax Number:
708-684-4272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4440 W 95TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK LAWN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60453-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-684-4116
Provider Business Practice Location Address Fax Number:
708-684-4272
Provider Enumeration Date:
08/18/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WX0002X , with the licence number:  209006718 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WX0003X , with the licence number: 209006718 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)