1992145676 NPI number — TARA LENORE SALCE NP

Table of content: TARA LENORE SALCE NP (NPI 1992145676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992145676 NPI number — TARA LENORE SALCE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALCE
Provider First Name:
TARA
Provider Middle Name:
LENORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CECIL
Provider Other First Name:
TARA
Provider Other Middle Name:
LENORE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992145676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N BEAVER ST
Provider Second Line Business Mailing Address:
PAYER CREDENTIALING
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-213-6235
Provider Business Mailing Address Fax Number:
928-213-6292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N BEAVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-773-2120
Provider Business Practice Location Address Fax Number:
928-773-2189
Provider Enumeration Date:
06/26/2013

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: 363LP0222X , with the licence number:  AP5130 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 860171 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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