Provider Demographics
NPI:1003083601
Name:TANYA ITANI TAIVAL DO LLC
Entity Type:Organization
Organization Name:TANYA ITANI TAIVAL DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:ITANI
Authorized Official - Last Name:TAIVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-269-0748
Mailing Address - Street 1:875 CENTURY MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2142
Mailing Address - Country:US
Mailing Address - Phone:321-269-0748
Mailing Address - Fax:321-383-2424
Practice Address - Street 1:875 CENTURY MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2142
Practice Address - Country:US
Practice Address - Phone:321-269-0748
Practice Address - Fax:321-383-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty