MEDICARE: RENIECE LARUE TATUM

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	174400000X	Specialist	085956	OH

General Provider Information

NPI Number	:	1992201800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENIECE LARUE TATUM

Provider Business Mailing Address
First Line	:	1358 TERRIER DR APT F
Second Line	:
City	:	COPLEY
State	:	OH
Zip	:	44321-2160
Country	:	US
Telephone Number	:	330-396-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 STORER AVE
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44320-2013
Country	:	US
Telephone Number	:	330-864-0228
Fax Number	:

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

Provider Enumeration Date	:	04/01/2018
Last Update Date	:	04/01/2018

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Directions to “ RENIECE LARUE TATUM ” Practice Location

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