Healthcare Provider Details

I. General information

NPI: 1023425915
Provider Name (Legal Business Name): TANJA LUTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2014
Last Update Date: 07/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 DOVER RD
BLOOMINGTON IL
61704-7608
US

IV. Provider business mailing address

1207 DOVER RD
BLOOMINGTON IL
61704-7608
US

V. Phone/Fax

Practice location:
  • Phone: 309-242-7567
  • Fax:
Mailing address:
  • Phone: 309-242-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number056004223
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: