1811061583 NPI number — MRS. LAURIE LYNNE TATE OTR

Table of content: MRS. LAURIE LYNNE TATE OTR (NPI 1811061583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811061583 NPI number — MRS. LAURIE LYNNE TATE OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATE
Provider First Name:
LAURIE
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1811061583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5623 HAMILTON WOLFE
Provider Second Line Business Mailing Address:
APT 321
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-3991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-340-2627
Provider Business Mailing Address Fax Number:
210-340-6437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 NE LOOP 410
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78216-5829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-340-2627
Provider Business Practice Location Address Fax Number:
210-340-6437
Provider Enumeration Date:
11/17/2006

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: 225X00000X , with the licence number:  111940 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8T6604 . This is a "BLUE CROSS BLUE SHEILD ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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