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General NPI Number Information
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NPI Number | 1558135574
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Entity Type | Individual
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Provider Name | TOM PLIVATUS ISHENGOMA
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Gender | Male
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Dates
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Enumeration Date | 11/09/2023
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Last Update Date | 11/09/2023
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Provider Practice Location Address
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Address Line | 19535 N 55TH DR
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City | GLENDALE
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State | AZ
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Zip | 85308-6805
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Country | US
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Telephone | 614-966-0671
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Fax |
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Provider Business Mailing Address
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Address Line | 3430 BOSTON AVE
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City | OAKLAND
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State | CA
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Zip | 94602-2906
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Country | US
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Telephone | 614-966-0671
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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