Provider Demographics
NPI:1366263865
Name:SADLOWSKI, TRACEY PHILYAW (OWNER)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:PHILYAW
Last Name:SADLOWSKI
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LAKESIDE AVE # 28630
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630-1752
Mailing Address - Country:US
Mailing Address - Phone:828-729-1950
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:51 LAKESIDE AVE # 28630
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-1752
Practice Address - Country:US
Practice Address - Phone:828-729-1950
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7690127172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver