Healthcare Provider Details

I. General information

NPI: 1023147089
Provider Name (Legal Business Name): TANAGER PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 C ST SW
CEDAR RAPIDS IA
52404-3707
US

IV. Provider business mailing address

2309 C ST SW
CEDAR RAPIDS IA
52404-3707
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-9164
  • Fax: 319-365-6411
Mailing address:
  • Phone: 319-365-9164
  • Fax: 319-365-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0470682
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MR. JEFF HUMISTON
Title or Position: C.F.O.
Credential:
Phone: 319-365-9165