Healthcare Provider Details

I. General information

NPI: 1124363486
Provider Name (Legal Business Name): BRIDGETT TILLMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 FOUNTAIN ST
TROY OH
45373-2816
US

IV. Provider business mailing address

818 FOUNTAIN ST
TROY OH
45373-2816
US

V. Phone/Fax

Practice location:
  • Phone: 937-451-2972
  • Fax:
Mailing address:
  • Phone: 937-451-2972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number144294
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number144294
License Number StateOH

VIII. Authorized Official

Name: MRS. BRIDGETT FAYE TILLMAN
Title or Position: LPN
Credential: LPN
Phone: 937-451-2972