MEDICARE: MR. CHARLES GENE TATUM JR.

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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1558227025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES GENE TATUM JR.

Provider Business Mailing Address
First Line	:	6400 SOUTHCENTER BLVD
Second Line	:
City	:	TUKWILA
State	:	WA
Zip	:	98188-2547
Country	:	US
Telephone Number	:	206-591-8389
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 16TH AVE E
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-5212
Country	:	US
Telephone Number	:	206-591-8389
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2025
Last Update Date	:	12/31/2025

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