Provider Demographics
NPI:1366061913
Name:TAVARES, AMELIA
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 GALESMORE CT
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1647
Mailing Address - Country:US
Mailing Address - Phone:209-402-1402
Mailing Address - Fax:
Practice Address - Street 1:1 VALLEY VIEW DR STE 104
Practice Address - Street 2:
Practice Address - City:MONTANA CITY
Practice Address - State:MT
Practice Address - Zip Code:59634-9203
Practice Address - Country:US
Practice Address - Phone:406-459-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN