Provider Demographics
NPI:1508992504
Name:TANAGER PLACE
Entity Type:Organization
Organization Name:TANAGER PLACE
Other - Org Name:
Other - Org Type:
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:319-365-9165
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:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2103614Medicaid