Healthcare Provider Details

I. General information

NPI: 1154291284
Provider Name (Legal Business Name): TANNER KING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 JACKSON ST
ANDERSON IN
46016-4337
US

IV. Provider business mailing address

14476 MILTON RD
FISHERS IN
46037-6421
US

V. Phone/Fax

Practice location:
  • Phone: 765-336-0665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number31006174A
License Number StateIN

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: