Provider Demographics
NPI:1396457164
Name:TATOOED COACH LLC
Entity type:Organization
Organization Name:TATOOED COACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COACH
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-299-5797
Mailing Address - Street 1:702 N GRAND ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 N GRAND ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3221
Practice Address - Country:US
Practice Address - Phone:405-299-5797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service