Healthcare Provider Details

I. General information

NPI: 1053079079
Provider Name (Legal Business Name): TANNER ALLEN HOTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CALEDONIA ST
LA CROSSE WI
54603-2616
US

IV. Provider business mailing address

1509 SOUTHCROSS DR W
BURNSVILLE MN
55306-6945
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-4100
  • Fax:
Mailing address:
  • Phone: 952-746-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: