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General NPI Number Information
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NPI Number | 1508185190
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Entity Type | Organization
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Legal Business Name | TANNER MEDICAL ENTERPRISES, INC
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Dates
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Enumeration Date | 05/23/2010
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Last Update Date | 03/04/2013
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Provider Practice Location Address
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Address Line | 101 FLORIDA BLVD
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City | NEPTUNE BEACH
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State | FL
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Zip | 32266-4966
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Country | US
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Telephone | 904-241-2653
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Fax | 904-246-6312
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Provider Business Mailing Address
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Address Line | PO BOX 51595
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32240-1595
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Country | US
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Telephone | 904-241-2653
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Fax | 904-246-6312
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Authorized Official
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Title or Position | ADMINISTRATOR/OWNER
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Name | MILLICENT H TANNER
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Credential |
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Telephone | 904-241-2653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS4709
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | OS4709
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | OS4709
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License Number State | FL
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