1437641297 NPI number — TALLEY DYAN THOMPSON CARPENTER DPT

Table of content: TALLEY DYAN THOMPSON CARPENTER DPT (NPI 1437641297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437641297 NPI number — TALLEY DYAN THOMPSON CARPENTER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON CARPENTER
Provider First Name:
TALLEY
Provider Middle Name:
DYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SURRETT
Provider Other First Name:
TALLEY
Provider Other Middle Name:
DYAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1437641297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3657 CORTEZ RD W STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34210-3171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-474-2700
Provider Business Mailing Address Fax Number:
941-474-8081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2828 S MCCALL RD STE 25
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34224-9517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-474-2700
Provider Business Practice Location Address Fax Number:
941-447-4808
Provider Enumeration Date:
06/06/2018

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: 208100000X , with the licence number:  PT33359 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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