Healthcare Provider Details

I. General information

NPI: 1730174194
Provider Name (Legal Business Name): TIM C GARL LATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

IV. Provider business mailing address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-2002
  • Fax: 812-855-9865
Mailing address:
  • Phone: 812-855-2002
  • Fax: 812-855-9865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36000012A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: