Provider Demographics
NPI:1376272088
Name:TAMERNIC
Entity Type:Organization
Organization Name:TAMERNIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JERYL
Authorized Official - Last Name:GOEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-607-1120
Mailing Address - Street 1:270 W MILKIWAY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE LILLIAN
Mailing Address - State:MN
Mailing Address - Zip Code:56253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 W MILKIWAY AVE
Practice Address - Street 2:
Practice Address - City:LAKE LILLIAN
Practice Address - State:MN
Practice Address - Zip Code:56253
Practice Address - Country:US
Practice Address - Phone:763-607-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1110595Other245D LICENSE
MN1112662OtherADULT FOSTER CARE LICENSE