Provider Demographics
NPI:1427826577
Name:TATUM, MANUEL (DRIVER LICENSE)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:TATUM
Suffix:
Gender:M
Credentials:DRIVER LICENSE
Other - Prefix:MR
Other - First Name:MANUEL
Other - Middle Name:
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RESPITE PROVIDER
Mailing Address - Street 1:322 STATE AVE UNIT 1123
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-4072
Mailing Address - Country:US
Mailing Address - Phone:562-341-3634
Mailing Address - Fax:
Practice Address - Street 1:322 STATE AVE UNIT 1123
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-4072
Practice Address - Country:US
Practice Address - Phone:562-341-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 372600000X
CAB7208559172A00000X
CA6058046735376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker