Provider Demographics
NPI:1376640482
Name:TAGUE, CURTIS
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:
Last Name:TAGUE
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:PO BOX 7630
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 E AIRPORT DR
Practice Address - Street 2:STE 201
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3472
Practice Address - Country:US
Practice Address - Phone:909-890-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246Q00000X, 246QM0706X, 246R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ67434ZOtherBLUE CROSS/BLUE SHIELD
CAZZZ24690ZMedicaid
P00147150Medicare PIN
CAZZZ67434ZOtherBLUE CROSS/BLUE SHIELD
CAZZZ24690ZMedicare PIN