Provider Demographics
NPI:1003315110
Name:JAIN, TARANG KUMAR
Entity Type:Individual
Prefix:
First Name:TARANG
Middle Name:KUMAR
Last Name:JAIN
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 1:5303 E CORTLAND BLVD APT B7
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-9567
Mailing Address - Country:US
Mailing Address - Phone:913-529-9906
Mailing Address - Fax:
Practice Address - Street 1:208 PINE KNOLL DR BLDG 66
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86011-0001
Practice Address - Country:US
Practice Address - Phone:928-523-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03913225100000X
MI5501013178225100000X
AZ11321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty