Provider Demographics
NPI:1053113035
Name:TABACCO, ROBERT J
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
Last Name:TABACCO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0201
Mailing Address - Country:US
Mailing Address - Phone:509-200-9201
Mailing Address - Fax:509-905-2052
Practice Address - Street 1:1129 S 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4100
Practice Address - Country:US
Practice Address - Phone:509-200-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator