Provider Demographics
NPI:1114083474
Name:TANAGER PLACE
Entity Type:Organization
Organization Name:TANAGER PLACE
Other - Org Name:TANAGER PLACE PMIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-365-9164
Mailing Address - Street 1:2309 C ST SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-3707
Mailing Address - Country:US
Mailing Address - Phone:319-365-9164
Mailing Address - Fax:319-365-6411
Practice Address - Street 1:2309 C ST SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3707
Practice Address - Country:US
Practice Address - Phone:319-365-9164
Practice Address - Fax:319-365-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA57PM-0005323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0047639Medicaid