1942534854 NPI number — MRS. TIARA SOARES VAN GINDERDEUREN OTR/L

Table of content: CESAR DAVID LEAL ROSARIO (NPI 1710732557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942534854 NPI number — MRS. TIARA SOARES VAN GINDERDEUREN OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GINDERDEUREN
Provider First Name:
TIARA
Provider Middle Name:
SOARES
Provider Name Prefix Text:
MRS.
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:
SOARES
Provider Other First Name:
TIARA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942534854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 BLYTHE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28203-5814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-355-4645
Provider Business Mailing Address Fax Number:
704-355-4231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 BEATY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELMONT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28012-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-822-2550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2009

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: 225X00000X , with the licence number:  7310 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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