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General NPI Number Information
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NPI Number | 1346087053
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Entity Type | Individual
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Provider Name | TARA EUGENIA MATHIS
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Gender | Female
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Dates
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Enumeration Date | 07/10/2024
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Last Update Date | 07/26/2024
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Provider Practice Location Address
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Address Line | 1657 COMMERCE DR STE 8B
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City | SOUTH BEND
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State | IN
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Zip | 46628-1542
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Country | US
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Telephone | 574-367-0395
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Fax | 844-894-8398
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Provider Business Mailing Address
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Address Line | 20200 MILLER RD
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City | SOUTH BEND
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State | IN
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Zip | 46614-9432
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Country | US
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Telephone | 574-367-0395
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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