Healthcare Provider Details

I. General information

NPI: 1225826720
Provider Name (Legal Business Name): KARL UDALVE TABORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 BAILEY AVE
NEEDLES CA
92363-3103
US

IV. Provider business mailing address

1510 E WAGON WHEEL LN STE 104
FORT MOHAVE AZ
86426-6698
US

V. Phone/Fax

Practice location:
  • Phone: 916-831-0782
  • Fax:
Mailing address:
  • Phone: 928-889-2273
  • Fax: 928-212-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95034737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: