MEDICARE: TABITHA VACHUSKA

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	3747P1801X	Personal Care Attendant	47-2951436	MN

General Provider Information

NPI Number	:	1447645544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA VACHUSKA

Provider Business Mailing Address
First Line	:	1200 W BROADWAY AVE
Second Line	:	SUITE # 160
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2572
Country	:	US
Telephone Number	:	612-353-6308
Fax Number	:	612-886-2708

Provider Business Practice Location Address
First Line	:	1200 W BROADWAY AVE
Second Line	:	SUITE # 160
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2572
Country	:	US
Telephone Number	:	612-353-6308
Fax Number	:	612-886-2708

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

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/06/2015

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