Provider Demographics
NPI:1922528173
Name:TACOMBINE LLC
Entity Type:Organization
Organization Name:TACOMBINE LLC
Other - Org Name:TACOMBINELLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-571-7629
Mailing Address - Street 1:215 H ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-4501
Mailing Address - Country:US
Mailing Address - Phone:515-571-7629
Mailing Address - Fax:
Practice Address - Street 1:215 H ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4501
Practice Address - Country:US
Practice Address - Phone:515-571-7629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TACOMBINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-20
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA034CC1132171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA812129105Medicaid
IA480176313Medicaid