Provider Demographics
NPI:1639537905
Name:TILLMAN, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 FLORA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-6202
Mailing Address - Country:US
Mailing Address - Phone:314-549-8503
Mailing Address - Fax:
Practice Address - Street 1:8210 FLORA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-6202
Practice Address - Country:US
Practice Address - Phone:314-549-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist