1437399474 NPI number — BEECH BROOK

Table of content: DR. GREGORY STEVEN TARDAGUILA D.C. (NPI 1629162631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437399474 NPI number — BEECH BROOK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEECH BROOK
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:
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:
1437399474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3737 LANDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEPPER PIKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44124-5712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-831-2255
Provider Business Mailing Address Fax Number:
216-831-0436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11801 BUCKEYE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44120-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-831-2255
Provider Business Practice Location Address Fax Number:
216-831-0436
Provider Enumeration Date:
03/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
REX
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
216-831-2255

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  12773 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12773 . This is a "OHIO DEPARTMENT OF ALCOHOL AND DRUG ADDICTION SERVICES" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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