Provider Demographics
NPI:1881218469
Name:TYCE, TASHA MARIE
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:MARIE
Last Name:TYCE
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 1:1218 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3021
Mailing Address - Country:US
Mailing Address - Phone:574-217-6214
Mailing Address - Fax:
Practice Address - Street 1:1218 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3021
Practice Address - Country:US
Practice Address - Phone:574-217-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-30
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71656343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN30037597Medicaid