MEDICARE: TANEKQUA WATTS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	172A00000X	Driver
2	343900000X	Non-emergency Medical Transport (VAN)
3	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1770953226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANEKQUA WATTS

Provider Business Mailing Address
First Line	:	811 WATTS AVE
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3436
Country	:	US
Telephone Number	:	843-593-2191
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 WATTS AVE
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3436
Country	:	US
Telephone Number	:	843-593-2191
Fax Number	:

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

Provider Enumeration Date	:	09/27/2015
Last Update Date	:	09/27/2015

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