Provider Demographics
NPI:1053971713
Name:TATUM, MELANEY ROSHAUN (CEO)
Entity type:Individual
Prefix:
First Name:MELANEY
Middle Name:ROSHAUN
Last Name:TATUM
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:EARNEST
Other - Middle Name:B
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COO
Mailing Address - Street 1:6605 HOGUE ST APT 10
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-6406
Mailing Address - Country:US
Mailing Address - Phone:936-899-8966
Mailing Address - Fax:
Practice Address - Street 1:6605 HOGUE ST APT 10
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-6406
Practice Address - Country:US
Practice Address - Phone:936-899-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-15
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251G00000X
TX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251G00000XAgenciesHospice Care, Community BasedGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84-1883213OtherDUNS