1134352560 NPI number — TATUM-MERE HEALTH AND COMMUNITY SERV INC.

Table of content: (NPI 1134352560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134352560 NPI number — TATUM-MERE HEALTH AND COMMUNITY SERV INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TATUM-MERE HEALTH AND COMMUNITY SERV INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST PAIN MANAGEMENT
Provider Other Organization Name Type Code:
3
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:
1134352560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208 HILLTOP DR STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82901-5859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-212-9472
Provider Business Mailing Address Fax Number:
307-460-7411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208 HILLTOP DR STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-212-9472
Provider Business Practice Location Address Fax Number:
307-460-7411
Provider Enumeration Date:
09/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PREISCH
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
307-212-9472

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131487400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121146000 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: W22909 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".




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