Provider Demographics
NPI:1629554563
Name:LAW, TIFFNEY
Entity Type:Individual
Prefix:
First Name:TIFFNEY
Middle Name:
Last Name:LAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 W CAPERTON ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-2308
Mailing Address - Country:US
Mailing Address - Phone:318-800-1785
Mailing Address - Fax:
Practice Address - Street 1:2838 W CAPERTON ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-2308
Practice Address - Country:US
Practice Address - Phone:318-800-1785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007256458347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle