Provider Demographics
NPI:1851679328
Name:DECOSTA, TOMARA
Entity Type:Individual
Prefix:
First Name:TOMARA
Middle Name:
Last Name:DECOSTA
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:PO BOX 15702
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0702
Mailing Address - Country:US
Mailing Address - Phone:919-886-7178
Mailing Address - Fax:
Practice Address - Street 1:3417 S ALSTON AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1517
Practice Address - Country:US
Practice Address - Phone:919-886-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist