1376866988 NPI number — MRS. DOMINIQUE LATASHA TERRY RDH

Table of content: MRS. DOMINIQUE LATASHA TERRY RDH (NPI 1376866988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376866988 NPI number — MRS. DOMINIQUE LATASHA TERRY RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERRY
Provider First Name:
DOMINIQUE
Provider Middle Name:
LATASHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
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:
1376866988
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2877 POPLAR AVENUE
Provider Second Line Business Mailing Address:
CHRIST COMMUNITY HEALTH SERVICES INC
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-324-0093
Provider Business Mailing Address Fax Number:
901-324-4029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2595 CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
CHRIST COMMUNITY HEALTH SERVICES INC
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-260-8551
Provider Business Practice Location Address Fax Number:
901-260-8590
Provider Enumeration Date:
03/10/2010

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: 124Q00000X , with the licence number:  DH05369 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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