MEDICARE: TAMMIE LUCINDA TIDWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747A0650X	Attendant Care Provider		CA

General Provider Information

NPI Number	:	1427607704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMIE LUCINDA TIDWELL

Provider Business Mailing Address
First Line	:	1700 RED ROCK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1232
Country	:	US
Telephone Number	:	702-406-9304
Fax Number	:	702-367-3445

Provider Business Practice Location Address
First Line	:	1700 RED ROCK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1232
Country	:	US
Telephone Number	:	702-406-9304
Fax Number	:	702-367-3445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2019
Last Update Date	:	09/09/2019

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Directions to “ TAMMIE LUCINDA TIDWELL ” Practice Location

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