Provider Demographics
NPI:1073240636
Name:MARYALICE HARDISON TELEMEDICINE PLLC
Entity Type:Organization
Organization Name:MARYALICE HARDISON TELEMEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARYALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-543-7064
Mailing Address - Street 1:707 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4203
Mailing Address - Country:US
Mailing Address - Phone:561-543-7064
Mailing Address - Fax:
Practice Address - Street 1:707 S 17TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4203
Practice Address - Country:US
Practice Address - Phone:561-543-7064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care