1184724833 NPI number — MRS. TARA K CHAVEZ RN

Table of content: MRS. TARA K CHAVEZ RN (NPI 1184724833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184724833 NPI number — MRS. TARA K CHAVEZ RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAVEZ
Provider First Name:
TARA
Provider Middle Name:
K
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ORR
Provider Other First Name:
TARA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184724833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4721 S PUEBLO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-803-0868
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SCHOOL DR
Provider Second Line Business Practice Location Address:
HUACHUCA CITY SCHOOL
Provider Business Practice Location Address City Name:
HUACHUCA CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-456-9842
Provider Business Practice Location Address Fax Number:
520-456-9811
Provider Enumeration Date:
09/23/2006

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: 163WS0200X , with the licence number:  RN106452 , 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: 036384 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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