Healthcare Provider Details

I. General information

NPI: 1437904919
Provider Name (Legal Business Name): TANNER LEE VINCENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date: 03/25/2025
Reactivation Date: 04/10/2025

III. Provider practice location address

3200 COLD SPRING RD
INDIANAPOLIS IN
46222-1960
US

IV. Provider business mailing address

2001 W 86TH ST
INDIANAPOLIS IN
46260-1902
US

V. Phone/Fax

Practice location:
  • Phone: 317-955-6000
  • Fax:
Mailing address:
  • Phone: 317-338-6399
  • Fax: 317-338-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: