Provider Demographics
NPI:1356925929
Name:TANNI SUPPORTIVE LIVING
Entity type:Organization
Organization Name:TANNI SUPPORTIVE LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TANNI
Authorized Official - Suffix:
Authorized Official - Credentials:AGNP-C
Authorized Official - Phone:847-868-3003
Mailing Address - Street 1:2698 BELVIDERE RD UNIT A01B
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-6006
Mailing Address - Country:US
Mailing Address - Phone:847-868-3003
Mailing Address - Fax:224-252-2997
Practice Address - Street 1:2698 BELVIDERE RD UNIT A01B
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-6006
Practice Address - Country:US
Practice Address - Phone:847-868-3003
Practice Address - Fax:224-252-2997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TANNI SUPPORTIVE LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL13876593OtherCAQH