Healthcare Provider Details

I. General information

NPI: 1679984447
Provider Name (Legal Business Name): MS. TINA C HILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E HIGHLAND ST
LA FARGE WI
54639-8647
US

IV. Provider business mailing address

402 E HIGHLAND ST
LA FARGE WI
54639-8647
US

V. Phone/Fax

Practice location:
  • Phone: 608-606-9321
  • Fax:
Mailing address:
  • Phone: 608-606-9321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License NumberH4008036064907
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberH4008036064907
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: