=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497048417
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TABONO CAP SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2011
-----------------------------------------------------
Last Update Date | 06/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16930 W CATAWBA AVE SUITE 100-C
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-5638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-892-1300
-----------------------------------------------------
Fax | 704-892-1505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 480428
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-5320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-892-1300
-----------------------------------------------------
Fax | 704-892-1505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. TAMARA D LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-892-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number | HC4110
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number | HC4110
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC4110
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------