=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235596685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TANGERE THERAPEUTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2016
-----------------------------------------------------
Last Update Date | 01/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4090 MARSHALL RD SUITE 2
-----------------------------------------------------
City | KETTERING
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-5168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-298-4325
-----------------------------------------------------
Fax | 937-504-5009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4090 MARSHALL RD SUITE 2
-----------------------------------------------------
City | KETTERING
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45429-5168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-298-4325
-----------------------------------------------------
Fax | 937-504-5009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JENNIFER PHIBBS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 937-298-4325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------