Provider Demographics
NPI:1215086731
Name:TACITO, CHARLIE ANDREW
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:ANDREW
Last Name:TACITO
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:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364
Mailing Address - Country:US
Mailing Address - Phone:901-278-1616
Mailing Address - Fax:901-278-0144
Practice Address - Street 1:1684 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-278-1616
Practice Address - Fax:901-278-0144
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNEMS00000100183416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3574503Medicare PIN