Healthcare Provider Details

I. General information

NPI: 1205983095
Provider Name (Legal Business Name): PATRICIA L TILLER CARE PROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E. EARP ST
HOLLY SPRINGS NC
27540-0582
US

IV. Provider business mailing address

PO BOX 582 312 E. EARP ST.
HOLLY SPRINGS NC
27540-0582
US

V. Phone/Fax

Practice location:
  • Phone: 919-552-4849
  • Fax: 919-557-7391
Mailing address:
  • Phone: 919-552-4849
  • Fax: 919-557-7391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License NumberFCL-092-042
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: