1508134883 NPI number — TRACY JOY GUTIERREZ MT

Table of content: TRACY JOY GUTIERREZ MT (NPI 1508134883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508134883 NPI number — TRACY JOY GUTIERREZ MT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
TRACY
Provider Middle Name:
JOY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT
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:
1508134883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 H STREET EAST
Provider Second Line Business Mailing Address:
LABORATORY
Provider Business Mailing Address City Name:
POPLAR
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59255-0067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-768-2172
Provider Business Mailing Address Fax Number:
406-768-3435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 H STREET EAST
Provider Second Line Business Practice Location Address:
LABORATORY
Provider Business Practice Location Address City Name:
POPLAR
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59255-0067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-768-2172
Provider Business Practice Location Address Fax Number:
406-768-3435
Provider Enumeration Date:
12/01/2011

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: 246ZA2600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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