1790111250 NPI number — MISS TAMMY KAYE MISKOVICH RDH, CDHC, ED

Table of content: MISS TAMMY KAYE MISKOVICH RDH, CDHC, ED (NPI 1790111250)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790111250 NPI number — MISS TAMMY KAYE MISKOVICH RDH, CDHC, ED

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
MISKOVICH

Provider First Name:
TAMMY

Provider Middle Name:
KAYE

Provider Name Prefix Text:
MISS

Provider Name Suffix Text:

Provider Credential Text:
RDH, CDHC, ED

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
MISKOVICH

Provider Other First Name:
TAMMY

Provider Other Middle Name:
KAYE

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:
RDA/RDH

Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790111250

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
09/16/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 851

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
DULUTH

Provider Business Mailing Address State Name:
MN

Provider Business Mailing Address Postal Code:
55801-0851

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
218-969-9886

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3614 MINNESOTA AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
DULUTH

Provider Business Practice Location Address State Name:
MN

Provider Business Practice Location Address Postal Code:
55802-2541

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
218-969-9886

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
09/16/2013

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: H5343 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .