1811037807 NPI number — MRS. TAMARA SUE CRUMMETT SUDCC II

Table of content: (NPI 1134764376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811037807 NPI number — MRS. TAMARA SUE CRUMMETT SUDCC II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUMMETT
Provider First Name:
TAMARA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SUDCC II
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:
1811037807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7233 S. DELIVERY DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRENCH CAMP
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-468-6857
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 N AURORA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95202-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-468-9370
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

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: 101YA0400X , with the licence number:  M0412181807 , 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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