Provider Demographics
NPI:1932960143
Name:SKILLOM, TALLY GARCIATH SAVALAS
Entity Type:Individual
Prefix:
First Name:TALLY
Middle Name:GARCIATH SAVALAS
Last Name:SKILLOM
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 1:2440 MERCURY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-4154
Mailing Address - Country:US
Mailing Address - Phone:513-476-3348
Mailing Address - Fax:
Practice Address - Street 1:2440 MERCURY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-4154
Practice Address - Country:US
Practice Address - Phone:513-476-3348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator