Provider Demographics
NPI:1235284423
Name:TANJER HOUSE
Entity Type:Organization
Organization Name:TANJER HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:ELZA
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:828-242-7835
Mailing Address - Street 1:161 E FRENCH BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3410
Mailing Address - Country:US
Mailing Address - Phone:828-884-2550
Mailing Address - Fax:828-884-2550
Practice Address - Street 1:161 E FRENCH BROAD ST
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-3410
Practice Address - Country:US
Practice Address - Phone:828-884-2550
Practice Address - Fax:828-884-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-088-015320600000X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418246Medicaid
NC7805680Medicaid