Healthcare Provider Details

I. General information

NPI: 1548422876
Provider Name (Legal Business Name): CHARLES H. TADLOCK, M.D. LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 MIAMI AVE
KINGMAN AZ
86401-4127
US

IV. Provider business mailing address

6725 S EASTERN AVE SUITE 6
LAS VEGAS NV
89119-3916
US

V. Phone/Fax

Practice location:
  • Phone: 702-474-0200
  • Fax: 702-946-5328
Mailing address:
  • Phone: 702-474-0200
  • Fax: 702-946-5328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4873
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4247
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number26067
License Number StateAZ

VIII. Authorized Official

Name: MRS. TAMMY R SHAFFER
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-474-0200