=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093348419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANOTHER WAY 1, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2020
-----------------------------------------------------
Last Update Date | 04/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5750 DIVISION ST
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-3269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-368-0428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | (TUTT) 1835 E. HALLANDALE BCH BLVD #127
-----------------------------------------------------
City | HALLANDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ZANDRA BERNETA TUTT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-937-2944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------