=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689057655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOHEME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2015
-----------------------------------------------------
Last Update Date | 07/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 CAUGHLIN XING
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89519-0613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-800-1724
-----------------------------------------------------
Fax | 775-800-1725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 CAUGHLIN XING
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89519-0613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-800-1724
-----------------------------------------------------
Fax | 775-800-1725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. TANYA PHARES
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 775-800-1724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------