MEDICARE: VIVIAN T ANUOLAM

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1346554995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN T ANUOLAM

Provider Business Mailing Address
First Line	:	13335 FALL MANOR DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-2431
Country	:	US
Telephone Number	:	469-337-3822
Fax Number	:

Provider Business Practice Location Address
First Line	:	13335 FALL MANOR DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-2431
Country	:	US
Telephone Number	:	469-337-3822
Fax Number	:

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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Directions to “ VIVIAN T ANUOLAM ” Practice Location

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