Provider Demographics
NPI:1518940840
Name:TAC ALPHA MEDICAL, INC.
Entity Type:Organization
Organization Name:TAC ALPHA MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:B
Authorized Official - Last Name:LUSK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-965-4466
Mailing Address - Street 1:423 DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-2377
Mailing Address - Country:US
Mailing Address - Phone:919-934-4555
Mailing Address - Fax:919-965-8483
Practice Address - Street 1:20 NOBLE ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9300
Practice Address - Country:US
Practice Address - Phone:919-934-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0737470001Medicare NSC