1184974065 NPI number — DR. TIFFANY ROSE DELANGE PT, DPT

Table of content: DR. TIFFANY ROSE DELANGE PT, DPT (NPI 1184974065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184974065 NPI number — DR. TIFFANY ROSE DELANGE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELANGE
Provider First Name:
TIFFANY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THALER
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
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:
1184974065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30516
Provider Second Line Business Mailing Address:
DEPT 5300
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48909-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-375-9450
Provider Business Mailing Address Fax Number:
269-375-9465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 MARCELL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49341-1365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-866-0141
Provider Business Practice Location Address Fax Number:
269-375-9465
Provider Enumeration Date:
09/18/2012

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: 225100000X , with the licence number:  5501015884 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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