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General NPI Number Information
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NPI Number | 1437582152
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Entity Type | Organization
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Legal Business Name | JOHN R TANNER OD PLLC
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Dates
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Enumeration Date | 08/16/2013
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Last Update Date | 08/16/2013
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Provider Practice Location Address
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Address Line | 18431 N 91ST AVE STE 1
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City | PEORIA
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State | AZ
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Zip | 85382-0817
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Country | US
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Telephone | 219-508-6465
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Fax |
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Provider Business Mailing Address
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Address Line | 18431 N 91ST AVE STE 1
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City | PEORIA
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State | AZ
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Zip | 85382-0817
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Country | US
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Telephone | 219-508-6465
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN R TANNER
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Credential | OD
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Telephone | 219-508-6465
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1935
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License Number State | AZ
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