1457266991 NPI number — TARA MARIA ETHERIDGE PPSC, LEP

Table of content: TARA MARIA ETHERIDGE PPSC, LEP (NPI 1457266991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457266991 NPI number — TARA MARIA ETHERIDGE PPSC, LEP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETHERIDGE
Provider First Name:
TARA
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PPSC, LEP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BELLEZZA
Provider Other First Name:
TARA
Provider Other Middle Name:
MARIA
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:
1457266991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1428 GREY OAKS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92056-6605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-695-9657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1428 GREY OAKS CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92056-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-695-9657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2026

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: 103T00000X , with the licence number:  LEP4561 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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