Healthcare Provider Details

I. General information

NPI: 1275677270
Provider Name (Legal Business Name): TARA L EYTCHESON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 E 100 N
KOKOMO IN
46901-3413
US

IV. Provider business mailing address

1539 E 100 N
KOKOMO IN
46901-3413
US

V. Phone/Fax

Practice location:
  • Phone: 765-450-5657
  • Fax: 765-450-6353
Mailing address:
  • Phone: 765-450-5657
  • Fax: 765-450-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: