Provider Demographics
NPI:1154927747
Name:ELAM, TARARNCE DERAIL
Entity type:Individual
Prefix:
First Name:TARARNCE
Middle Name:DERAIL
Last Name:ELAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 RUSSELL SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-7280
Mailing Address - Country:US
Mailing Address - Phone:434-473-2262
Mailing Address - Fax:
Practice Address - Street 1:491 RUSSELL SPRINGS DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-7280
Practice Address - Country:US
Practice Address - Phone:434-473-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60711698343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)