1407989940 NPI number — CHAD DOUGLAS TANNER BSWAM LMT,CMT

Table of content: JOANNE G DEVORE MD (NPI 1023007036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407989940 NPI number — CHAD DOUGLAS TANNER BSWAM LMT,CMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNER
Provider First Name:
CHAD
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSWAM LMT,CMT
Provider Gender Code:
M

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:
1407989940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARDWICK
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05843-0091
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-279-3839
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 S MAIN ST
Provider Second Line Business Practice Location Address:
HARDWICK INN 3RD FLOOR SUITE 10
Provider Business Practice Location Address City Name:
HARDWICK
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-279-3839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2007

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: 225700000X , with the licence number:  MAT-9525 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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