1730402025 NPI number — DINA K TACK MD

Table of content: DINA K TACK MD (NPI 1730402025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730402025 NPI number — DINA K TACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TACK
Provider First Name:
DINA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1730402025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4540
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89702-4540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-882-0430
Provider Business Mailing Address Fax Number:
775-852-6902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1535 MEDICAL CENTER PARKWAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CARSON CITY
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89703-4367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-445-7960
Provider Business Practice Location Address Fax Number:
775-883-3395
Provider Enumeration Date:
03/01/2010

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: 207RX0202X , with the licence number:  13333 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RX0202X , with the licence number: 1333 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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