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NPI Code Detail

MEDICARE: TAMARA WILLARD

MEDICARE: TAMARA WILLARD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251S00000XCommunity/Behavioral Health Agency4859SC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1215462742
Entity Type Code : Organization
Provider Name (Legal Business Name) : TAMARA WILLARD
Provider Business Mailing Address
First Line : 4221 MAYFAIR ST
Second Line :
City : MYRTLE BEACH
State : SC
Zip : 29577-5757
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4221 MAYFAIR ST
Second Line :
City : MYRTLE BEACH
State : SC
Zip : 29577-5757
Country : US
Telephone Number : 843-360-9491
Fax Number :
Authorized Official
Title or Position : OWNER
Name : TAMARA WILLARD
Credential :
Telephone Number : 843-360-9491
Provider Enumeration Date : 04/21/2017
Last Update Date : 04/21/2017

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