1104851625 NPI number — TAMARAC MEDICAL INC

Table of content: (NPI 1104851625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104851625 NPI number — TAMARAC MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAMARAC MEDICAL INC
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:
1104851625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3959 E ARAPAHOE RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
CENTENNIAL
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80122-2070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-794-1083
Provider Business Mailing Address Fax Number:
303-794-1093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3959 E ARAPAHOE RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
CENTENNIAL
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80122-2070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-794-1083
Provider Business Practice Location Address Fax Number:
303-794-1093
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENBAUM
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
LABORATORY DIRECTOR
Authorized Official Telephone Number:
303-794-1083

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  06D0899927 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00666014A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100759250A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 343719100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100245360A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146949709 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1662275 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 705766301 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08002669 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200061470 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000100188 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0123731 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: J4463 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0153711 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06D0899927 . This is a "CLIA NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6705072000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: C05800044 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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