Provider Demographics
NPI:1922214857
Name:EMBRY, THOMAS TALAVERA (PATIENT CARE TECH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:TALAVERA
Last Name:EMBRY
Suffix:
Gender:M
Credentials:PATIENT CARE TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27433 CAPRI AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4001
Mailing Address - Country:US
Mailing Address - Phone:510-487-2891
Mailing Address - Fax:510-487-2891
Practice Address - Street 1:27433 CAPRI AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4001
Practice Address - Country:US
Practice Address - Phone:510-487-2891
Practice Address - Fax:510-487-2891
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3382190172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN00905FOtherMEDI-CAL PROVIDER'S NUMBE