1790929438 NPI number — MRS. TARA LOVETT DETTRA L.M., C.P.M.

Table of content: MRS. TARA LOVETT DETTRA L.M., C.P.M. (NPI 1790929438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790929438 NPI number — MRS. TARA LOVETT DETTRA L.M., C.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETTRA
Provider First Name:
TARA
Provider Middle Name:
LOVETT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.M., C.P.M.
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:
1790929438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1093 A1A BEACH BLVD
Provider Second Line Business Mailing Address:
PMB 285
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32080-6733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-540-7994
Provider Business Mailing Address Fax Number:
904-471-4980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1093 A1A BEACH BLVD
Provider Second Line Business Practice Location Address:
PMB 285
Provider Business Practice Location Address City Name:
SAINT AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32080-6733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-540-7994
Provider Business Practice Location Address Fax Number:
904-471-4980
Provider Enumeration Date:
04/24/2009

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: 176B00000X , with the licence number:  MW 227 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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