Provider Demographics
NPI:1083224240
Name:SUSAN TANNER TANNER HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:SUSAN TANNER TANNER HEALTHCARE SERVICES, LLC
Other - Org Name:TANNER HEALTHCARE SERVICES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:302-399-6509
Mailing Address - Street 1:546 LONG PINE DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7298
Mailing Address - Country:US
Mailing Address - Phone:302-399-6509
Mailing Address - Fax:803-708-3743
Practice Address - Street 1:546 LONG PINE DRIVE
Practice Address - Street 2:
Practice Address - City:BYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016
Practice Address - Country:US
Practice Address - Phone:302-399-6509
Practice Address - Fax:803-708-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4870Medicaid