=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033834130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREEZE MOBILE PHLEBOTOMY & MORE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 CHURCH ST FL 19
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-584-6033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 157 CHURCH ST FL 19
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06510-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-444-4833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PREDIDENT
-----------------------------------------------------
Name | TABISHA JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-584-6033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246W00000X
-----------------------------------------------------
Taxonomy Name | Cardiology Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372500000X
-----------------------------------------------------
Taxonomy Name | Chore Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 374700000X
-----------------------------------------------------
Taxonomy Name | Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------