Provider Demographics
NPI:1497102842
Name:TANCO, KALIL
Entity Type:Individual
Prefix:
First Name:KALIL
Middle Name:
Last Name:TANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20132 NW 37TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1435
Mailing Address - Country:US
Mailing Address - Phone:786-762-5692
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician