Provider Demographics
NPI:1124363486
Name:BRIDGETT TILLMAN
Entity Type:Organization
Organization Name:BRIDGETT TILLMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:937-451-2972
Mailing Address - Street 1:818 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2816
Mailing Address - Country:US
Mailing Address - Phone:937-451-2972
Mailing Address - Fax:
Practice Address - Street 1:818 FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2816
Practice Address - Country:US
Practice Address - Phone:937-451-2972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH144294251E00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite Care