MEDICARE: TAMISHA LAQUINNA LOUDER

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
1	1744P3200X	Prosthetics Case Management	CO127306	GA

General Provider Information

NPI Number	:	1568824407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMISHA LAQUINNA LOUDER

Provider Business Mailing Address
First Line	:	1214N COLUMBIA AVENUE UNIT B
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326
Country	:	US
Telephone Number	:	912-412-4568
Fax Number	:

Provider Business Practice Location Address
First Line	:	1214 N COLUMBIA AVE STE B
Second Line	:
City	:	RINCON
State	:	GA
Zip	:	31326-6815
Country	:	US
Telephone Number	:	912-412-4568
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2016
Last Update Date	:	03/21/2016

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