Provider Demographics
NPI:1639460371
Name:TATASHADZE, ELEONORA (PROVIDER)
Entity Type:Individual
Prefix:
First Name:ELEONORA
Middle Name:
Last Name:TATASHADZE
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:ELEONORA
Other - Middle Name:
Other - Last Name:TATASHADZE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PROVIDER
Mailing Address - Street 1:6613 FINEGAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-7112
Mailing Address - Country:US
Mailing Address - Phone:860-726-6200
Mailing Address - Fax:
Practice Address - Street 1:6613 FINEGAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-7112
Practice Address - Country:US
Practice Address - Phone:860-726-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000493171WH0202X
OH4203630171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4203630OtherSTATE OF OHIO CERTIFICATE
CT0000493OtherNON MEDICAL HOMEMAKER COMPANION AGENCY