Provider Demographics
NPI:1144971565
Name:TATUM, JOSEPH AMOS SR
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:AMOS
Last Name:TATUM
Suffix:SR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOSEPH
Other - Middle Name:AMOS
Other - Last Name:TATUM
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:ROAD RUNNERS LLC
Mailing Address - Street 1:102 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-3109
Mailing Address - Country:US
Mailing Address - Phone:505-592-2851
Mailing Address - Fax:
Practice Address - Street 1:102 W 26TH ST
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-3109
Practice Address - Country:US
Practice Address - Phone:505-592-2851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20218177072172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1993Other.