Healthcare Provider Details

I. General information

NPI: 1427607704
Provider Name (Legal Business Name): TAMMIE LUCINDA TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 RED ROCK ST
LAS VEGAS NV
89146-1232
US

IV. Provider business mailing address

1700 RED ROCK ST
LAS VEGAS NV
89146-1232
US

V. Phone/Fax

Practice location:
  • Phone: 702-406-9304
  • Fax: 702-367-3445
Mailing address:
  • Phone: 702-406-9304
  • Fax: 702-367-3445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: