Provider Demographics
NPI:1013441823
Name:TAHERI, ROYA
Entity type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:TAHERI
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 1:2511 SICKLE WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-4552
Mailing Address - Country:US
Mailing Address - Phone:910-964-3911
Mailing Address - Fax:
Practice Address - Street 1:1700 PAMALEE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-2824
Practice Address - Country:US
Practice Address - Phone:910-849-2096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA4980261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center