=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922736214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANI&FLOW VENIPUNCTURE COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2022
-----------------------------------------------------
Last Update Date | 08/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1880 N STATE ROUTE 50 STE 4
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-386-0981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 189 N QUINCY AVE
-----------------------------------------------------
City | BRADLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60915-1841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-386-0981
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | MS. FLORENCE LANE
-----------------------------------------------------
Credential | CNA, CPT
-----------------------------------------------------
Telephone | 815-386-0981
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------