Healthcare Provider Details

I. General information

NPI: 1629768528
Provider Name (Legal Business Name): TIARA MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 GRELOT RD STE G1420
MOBILE AL
36609-3602
US

IV. Provider business mailing address

4141 WILDFORK RD
BREWTON AL
36426-6161
US

V. Phone/Fax

Practice location:
  • Phone: 251-238-7723
  • Fax:
Mailing address:
  • Phone: 251-238-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: