Healthcare Provider Details

I. General information

NPI: 1417860164
Provider Name (Legal Business Name): TATE D PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E MAIN ST
GRAHAM NC
27253-8547
US

IV. Provider business mailing address

1208 E MAIN ST
GRAHAM NC
27253-8547
US

V. Phone/Fax

Practice location:
  • Phone: 336-972-2679
  • Fax:
Mailing address:
  • Phone: 336-972-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number000044383480
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: