1821820606 NPI number — TIELISHA CHAVANNES HODGES OWNER

Table of content: TIELISHA CHAVANNES HODGES OWNER (NPI 1821820606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821820606 NPI number — TIELISHA CHAVANNES HODGES OWNER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HODGES
Provider First Name:
TIELISHA
Provider Middle Name:
CHAVANNES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OWNER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TRANSPORTATION
Provider Other First Name:
TIELISHAS ALL
Provider Other Middle Name:
PURPOSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821820606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4608 N 18TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209-6429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-975-5106
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4608 N 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53209-6429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-975-5106
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2024

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: 342000000X , with the licence number:  H3228038264807 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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