MEDICARE: TYQUANA T BASS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	251J00000X	Nursing Care Agency	FL
2	372600000X	Adult Companion
3	251E00000X	Home Health Agency	FL

General Provider Information

NPI Number	:	1538728621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYQUANA T BASS

Provider Business Mailing Address
First Line	:	PO BOX 471452
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33247-1452
Country	:	US
Telephone Number	:	305-417-1941
Fax Number	:

Provider Business Practice Location Address
First Line	:	3820 NW 170TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33055-4529
Country	:	US
Telephone Number	:	305-417-1941
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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Directions to “ TYQUANA T BASS ” Practice Location

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