1073001566 NPI number — TIMISHA MAHOGANY RENEAU

Table of content: TIMISHA MAHOGANY RENEAU (NPI 1073001566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073001566 NPI number — TIMISHA MAHOGANY RENEAU

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENEAU
Provider First Name:
TIMISHA
Provider Middle Name:
MAHOGANY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1073001566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
994 S HARRISON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85748-6608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-721-1887
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36509 W PADILLA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARICOPA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85138-2099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-612-2894
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2018

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: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9218197 . This is a "HCTC THERAPEUTIC FOSTER CARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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