1104177567 NPI number — CARNAGE TENDER LOVING CARE ADC

Table of content: TIMOTHY MATTHEW RYAN CMS (NPI 1245899053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104177567 NPI number — CARNAGE TENDER LOVING CARE ADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARNAGE TENDER LOVING CARE ADC
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:
6
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:
1104177567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 474
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITTA BENA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38941-0474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-254-0011
Provider Business Mailing Address Fax Number:
662-254-9511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 WHEELER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITTA BENA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38941-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-254-0011
Provider Business Practice Location Address Fax Number:
662-254-9511
Provider Enumeration Date:
09/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CARNAGE
Authorized Official First Name:
AUGUSTA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-254-6107

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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