MEDICARE: TENNILE LAAKEAOUALANI TAVARES

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	106S00000X	Behavior Technician		NV

General Provider Information

NPI Number	:	1568119584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TENNILE LAAKEAOUALANI TAVARES

Provider Business Mailing Address
First Line	:	2455 W SERENE AVE UNIT 3-549
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6559
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2455 W SERENE AVE UNIT 3-549
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6559
Country	:	US
Telephone Number	:	808-797-5075
Fax Number	:

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

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/16/2022

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Directions to “ TENNILE LAAKEAOUALANI TAVARES ” Practice Location

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