1932454907 NPI number — MARIANNE DECAIN TARRAZA NP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932454907 NPI number — MARIANNE DECAIN TARRAZA NP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIANNE DECAIN TARRAZA NP, LLC
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:
1932454907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04116-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-312-1063
Provider Business Mailing Address Fax Number:
207-375-5165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 SHORE RD
Provider Second Line Business Practice Location Address:
BUILDING #326
Provider Business Practice Location Address City Name:
CAPE ELIZABETH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04107-1916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-312-1063
Provider Business Practice Location Address Fax Number:
207-375-5165
Provider Enumeration Date:
07/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FOURNIER
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CREDENTIALING BILLING REP
Authorized Official Telephone Number:
207-312-1063

Provider Taxonomy Codes

  • Taxonomy code: 163WP0809X , with the licence number:  CNP81164 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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