1467822320 NPI number — MRS. TARA D HUMPHREYS LAT, ATC

Table of content: MRS. TARA D HUMPHREYS LAT, ATC (NPI 1467822320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467822320 NPI number — MRS. TARA D HUMPHREYS LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUMPHREYS
Provider First Name:
TARA
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LAT, 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:
1467822320
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12345 E LEGAL TENDER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47203-9424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-350-7495
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W BASSETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46176-8574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-392-2161
Provider Business Practice Location Address Fax Number:
317-398-1870
Provider Enumeration Date:
10/03/2015

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: 207XX0005X , with the licence number:  36001308A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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