1275822108 NPI number — MRS. FARZANEH TAVASSOLI FORTIER RPH

Table of content: MRS. FARZANEH TAVASSOLI FORTIER RPH (NPI 1275822108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275822108 NPI number — MRS. FARZANEH TAVASSOLI FORTIER RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTIER
Provider First Name:
FARZANEH
Provider Middle Name:
TAVASSOLI
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1275822108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2608 BADGER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURGIS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57785-2248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-720-9579
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 MT RUSHMORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAPID CITY
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-718-4040
Provider Business Practice Location Address Fax Number:
605-718-2650
Provider Enumeration Date:
03/31/2011

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: 183500000X , with the licence number:  4616 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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