Provider Demographics
NPI:1538756630
Name:TIA DWANA COLLECTION LLC
Entity type:Organization
Organization Name:TIA DWANA COLLECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-532-3475
Mailing Address - Street 1:7643 GATE PKWY STE 104-333
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7643 GATE PKWY STE 104-333
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-2893
Practice Address - Country:US
Practice Address - Phone:904-532-3475
Practice Address - Fax:904-977-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-23
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier