=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578909594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TANIS PHILLIPS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2013
-----------------------------------------------------
Last Update Date | 05/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 98 CATHEDRAL LN
-----------------------------------------------------
City | CHEEKTOWAGA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14225-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-253-4270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 CATHEDRAL LN
-----------------------------------------------------
City | CHEEKTOWAGA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14225-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-253-4270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPN
-----------------------------------------------------
Name | TANIS JOY PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-253-4270
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | 314090-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------