1831212067 NPI number — TACKLE MANAGEMENT CORPORATION

Table of content: (NPI 1831212067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831212067 NPI number — TACKLE MANAGEMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TACKLE MANAGEMENT CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1831212067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8637 MATHIS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-5270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-368-1800
Provider Business Mailing Address Fax Number:
703-392-4820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8637 MATHIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-5270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-368-1800
Provider Business Practice Location Address Fax Number:
703-392-4820
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COATES
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
703-368-1800

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  0103000741 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C10314 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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