1285992693 NPI number — TARA ELIZABETH FONTENOT PT, DPT, OCS, ATC

Table of content: TARA ELIZABETH FONTENOT PT, DPT, OCS, ATC (NPI 1285992693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285992693 NPI number — TARA ELIZABETH FONTENOT PT, DPT, OCS, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTENOT
Provider First Name:
TARA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, OCS, ATC
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:
1285992693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 ALBEMARLE SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22901-7405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-817-7848
Provider Business Mailing Address Fax Number:
434-465-6834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2114 ANGUS RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22901-2768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-295-4473
Provider Business Practice Location Address Fax Number:
434-985-3227
Provider Enumeration Date:
04/24/2012

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:  2305207356 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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