Basic Information
| Provider Information | |||||||||
| NPI: | 1225551856 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA ROMEO TANGO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 236105 | ||||||||
| Address2: | |||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920236105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583002626 | ||||||||
| FaxNumber: | 8584089400 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 COMMERCIAL WAY | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829014753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583002626 | ||||||||
| FaxNumber: | 8584089400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | TANTAUWAYA | ||||||||
| AuthorizedOfficialFirstName: | LOKESH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8583002626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 10014A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.