Provider Demographics
NPI:1174573489
Name:TLC FAMILY MEDICINE PC
Entity type:Organization
Organization Name:TLC FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNINO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-598-1357
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 131
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-598-1357
Mailing Address - Fax:480-598-3070
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:SUITE 131
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-598-1357
Practice Address - Fax:480-598-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ77390Medicare PIN