1164707378 NPI number — MS. ANDREA L TAIT P.T.

Table of content: MS. ANDREA L TAIT P.T. (NPI 1164707378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164707378 NPI number — MS. ANDREA L TAIT P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAIT
Provider First Name:
ANDREA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1164707378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6311 LAMBERT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14564-9254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-944-4664
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
953 HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTOR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14564-1168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-924-3252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2011

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: 2251P0200X , with the licence number:  021124 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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