Healthcare Provider Details

I. General information

NPI: 1548964331
Provider Name (Legal Business Name): TERRA TILLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 MORSE RD
COLUMBUS OH
43219-3016
US

IV. Provider business mailing address

3900 MORSE RD
COLUMBUS OH
43219-3016
US

V. Phone/Fax

Practice location:
  • Phone: 614-476-2086
  • Fax:
Mailing address:
  • Phone: 614-476-2086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.017242-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: