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General NPI Number Information
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NPI Number | 1548422876
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Entity Type | Organization
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Legal Business Name | CHARLES H. TADLOCK, M.D. LTD.
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Dates
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Enumeration Date | 06/27/2008
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 1912 MIAMI AVE
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City | KINGMAN
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State | AZ
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Zip | 86401-4127
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Country | US
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Telephone | 702-474-0200
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Fax | 702-946-5328
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Provider Business Mailing Address
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Address Line | 6725 S EASTERN AVE SUITE 6
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City | LAS VEGAS
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State | NV
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Zip | 89119-3916
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Country | US
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Telephone | 702-474-0200
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Fax | 702-946-5328
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. TAMMY R SHAFFER
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Credential |
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Telephone | 702-474-0200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 4873
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP4247
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 26067
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License Number State | AZ
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