MEDICARE: TIMOTHY GLENN EIKOM

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	246RM2200X	Medical Laboratory Technician

General Provider Information

NPI Number	:	1740678887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY GLENN EIKOM

Provider Business Mailing Address
First Line	:	5448 MIDWINTER MIST ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-7937
Country	:	US
Telephone Number	:	760-953-0739
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 N US HIGHWAY 89
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86313-5001
Country	:	US
Telephone Number	:	928-445-4860
Fax Number	:

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

Provider Enumeration Date	:	12/23/2014
Last Update Date	:	12/23/2014

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Directions to “ TIMOTHY GLENN EIKOM ” Practice Location

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