Healthcare Provider Details

I. General information

NPI: 1679403497
Provider Name (Legal Business Name): MATTHEW TANKOVICH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LAKE VISTA DR
CHAPIN SC
29036-8472
US

IV. Provider business mailing address

125 LAKE VISTA DR
CHAPIN SC
29036-8472
US

V. Phone/Fax

Practice location:
  • Phone: 678-849-0923
  • Fax:
Mailing address:
  • Phone: 678-849-0923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number268415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: