MEDICARE: VIRGINA DAWN BOWLING FOSTER PARENT

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	385HR2055X	Child Mental Illness Respite Care	11030	AZ

General Provider Information

NPI Number	:	1316002017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINA DAWN BOWLING FOSTER PARENT

Provider Business Mailing Address
First Line	:	2829 W 27TH LN
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-6857
Country	:	US
Telephone Number	:	928-317-9064
Fax Number	:

Provider Business Practice Location Address
First Line	:	2829 W 27TH LN
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-6857
Country	:	US
Telephone Number	:	928-317-9064
Fax Number	:

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

Provider Enumeration Date	:	12/25/2006
Last Update Date	:	07/08/2007

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