Healthcare Provider Details

I. General information

NPI: 1326595786
Provider Name (Legal Business Name): MICHAEL TILLERY R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 SAIL MAKER LN
RICHMOND HILL GA
31324-6260
US

IV. Provider business mailing address

65 SAIL MAKER LN
RICHMOND HILL GA
31324-6260
US

V. Phone/Fax

Practice location:
  • Phone: 619-804-5766
  • Fax:
Mailing address:
  • Phone: 619-804-5766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number702631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: