Healthcare Provider Details

I. General information

NPI: 1366009961
Provider Name (Legal Business Name): TAHOMA ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 BALDWIN ST
JENISON MI
49428-8937
US

IV. Provider business mailing address

1346 BALDWIN ST
JENISON MI
49428-8937
US

V. Phone/Fax

Practice location:
  • Phone: 616-765-8585
  • Fax:
Mailing address:
  • Phone: 616-765-8585
  • Fax: 616-333-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: SALENA CORNER
Title or Position: OWNER
Credential: LMSW
Phone: 616-765-8585