1760732465 NPI number — TAMARA NICOLE HARTENBERGER P.T.

Table of content: TAMARA NICOLE HARTENBERGER P.T. (NPI 1760732465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760732465 NPI number — TAMARA NICOLE HARTENBERGER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARTENBERGER
Provider First Name:
TAMARA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1760732465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 HIGHWAY 314 SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS LUNAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87031-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-866-0055
Provider Business Mailing Address Fax Number:
505-866-0057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4516 ARROWHEAD RIDGE DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-5932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-896-4978
Provider Business Practice Location Address Fax Number:
505-994-2842
Provider Enumeration Date:
09/11/2012

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: 225100000X , with the licence number:  4208 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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