1396081808 NPI number — TIFFANIE CHRISTEEN GONZALES CPM CLC

Table of content: TIFFANIE CHRISTEEN GONZALES CPM CLC (NPI 1396081808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396081808 NPI number — TIFFANIE CHRISTEEN GONZALES CPM CLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
TIFFANIE
Provider Middle Name:
CHRISTEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPM CLC
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:
1396081808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 S EASTERN AVE STE 9A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89119-3153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-448-9428
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8826 S EASTERN AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89123-4824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-448-9428
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2013

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: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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