1922149483 NPI number — CAROL TIETZ OTR L

Table of content: CAROL TIETZ OTR L (NPI 1922149483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922149483 NPI number — CAROL TIETZ OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIETZ
Provider First Name:
CAROL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR L
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:
1922149483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6325 MONTANA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34653-3833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-809-3326
Provider Business Mailing Address Fax Number:
727-845-1811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10521 HEARTH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING HILL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34608-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-683-7117
Provider Business Practice Location Address Fax Number:
727-845-1811
Provider Enumeration Date:
02/09/2007

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: 225XP0200X , with the licence number:  OT1010 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10656001 . This is a "CITRUS HEALTHCARE NPR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 880317000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10656002 . This is a "CITRUS HEALTHCARE SH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 880317000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com