MEDICARE: MIRANDA TATOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker
2	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care

General Provider Information

NPI Number	:	1013649490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA TATOM

Provider Business Mailing Address
First Line	:	3292 BENCHWOOD RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-2704
Country	:	US
Telephone Number	:	937-668-1729
Fax Number	:

Provider Business Practice Location Address
First Line	:	3292 BENCHWOOD RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-2704
Country	:	US
Telephone Number	:	937-668-1729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2022
Last Update Date	:	06/25/2022

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Directions to “ MIRANDA TATOM ” Practice Location

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