Healthcare Provider Details

I. General information

NPI: 1841782968
Provider Name (Legal Business Name): TIFFANY PINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12561 WARDLINE RD
HAMMOND LA
70401-6212
US

IV. Provider business mailing address

12561 WARDLINE RD
HAMMOND LA
70401-6212
US

V. Phone/Fax

Practice location:
  • Phone: 985-551-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: