Provider Demographics
NPI:1952031791
Name:LANGAN, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LANGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:52756-8721
Mailing Address - Country:US
Mailing Address - Phone:563-370-3097
Mailing Address - Fax:
Practice Address - Street 1:307 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IA
Practice Address - Zip Code:52756-8721
Practice Address - Country:US
Practice Address - Phone:563-370-3097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA778AA3540172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver