Healthcare Provider Details

I. General information

NPI: 1346851417
Provider Name (Legal Business Name): TATIANA TVRDIK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TATIANA BASTLOVA PHD

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

2830 S 2750 E
SALT LAKE CITY UT
84109-2017
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-4810
  • Fax: 404-712-4349
Mailing address:
  • Phone: 801-739-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number20027SP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: