MEDICARE: TAHOMA ENTERPRISES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1366009961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAHOMA ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	1346 BALDWIN ST
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-8937
Country	:	US
Telephone Number	:	616-765-8585
Fax Number	:	616-333-8116

Provider Business Practice Location Address
First Line	:	1346 BALDWIN ST
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-8937
Country	:	US
Telephone Number	:	616-765-8585
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SALENA CORNER
Credential	:	LMSW
Telephone Number	:	616-765-8585

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	02/05/2026

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Directions to “TAHOMA ENTERPRISES LLC ” Practice Location

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