=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104050442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYLAH NO.1
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2009
-----------------------------------------------------
Last Update Date | 05/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 SYCAMORE ST
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 SYCAMORE ST
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-693-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DENNIS SPENCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-693-8299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | FCL-039-010
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------