Healthcare Provider Details

I. General information

NPI: 1174573489
Provider Name (Legal Business Name): TLC FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST SUITE 131
PHOENIX AZ
85048-0558
US

IV. Provider business mailing address

16515 S 40TH ST SUITE 131
PHOENIX AZ
85048-0558
US

V. Phone/Fax

Practice location:
  • Phone: 480-598-1357
  • Fax: 480-598-3070
Mailing address:
  • Phone: 480-598-1357
  • Fax: 480-598-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY MANNINO
Title or Position: PRESIDENT CEO
Credential: DO
Phone: 480-598-1357