Provider Demographics
NPI:1003500042
Name:SCURRY, TAVONTE
Entity Type:Individual
Prefix:
First Name:TAVONTE
Middle Name:
Last Name:SCURRY
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 1:1088 EASTWAY DR APT 9
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-4682
Mailing Address - Country:US
Mailing Address - Phone:330-719-6812
Mailing Address - Fax:
Practice Address - Street 1:1088 EASTWAY DR APT 9
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-4682
Practice Address - Country:US
Practice Address - Phone:330-719-6812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTG518752172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty