MEDICARE: PHYLLIS BOB-HARRIS

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	164X00000X	Licensed Vocational Nurse	202483	CA

General Provider Information

NPI Number	:	1922455674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS BOB-HARRIS

Provider Business Mailing Address
First Line	:	2108 PETUNIA ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75228-5685
Country	:	US
Telephone Number	:	972-748-8485
Fax Number	:

Provider Business Practice Location Address
First Line	:	2108 PETUNIA ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75228-5685
Country	:	US
Telephone Number	:	972-748-8485
Fax Number	:

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

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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