Provider Demographics
NPI:1780220079
Name:COLEMAN, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COLEMAN
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 1:808 E. 63RD STREET
Mailing Address - Street 2:SUITE 135
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-960-1286
Mailing Address - Fax:
Practice Address - Street 1:808 E. 63RD STREET
Practice Address - Street 2:SUITE 135
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-960-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILC45581877609343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)