MEDICARE: BRITTANI TILLIS

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	225700000X	Massage Therapist	MT118707	TX

General Provider Information

NPI Number	:	1780090175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRITTANI TILLIS

Provider Business Mailing Address
First Line	:	7905 MARVIN D LOVE FWY APT 621
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-3476
Country	:	US
Telephone Number	:	469-585-6557
Fax Number	:

Provider Business Practice Location Address
First Line	:	3314 W KIEST BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75233-2102
Country	:	US
Telephone Number	:	214-623-0505
Fax Number	:

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

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	07/07/2014

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