=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174927016
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TFM SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2014
-----------------------------------------------------
Last Update Date | 10/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27885 IRMA LEE CIR STE 105
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-5129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-302-8176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1175 ANDERSON DR
-----------------------------------------------------
City | GREEN OAKS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-302-8176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS F MIENTUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-302-8176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 336.075460
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------