Organization
TANAGER PLACE
Active
Other names
Tanager Place PMIC
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JEFF HUMISTON (C.F.O.)
(319) 365-9164
Entity
Organization
Contact information
Practice address
2309 C ST SW, CEDAR RAPIDS, IA 52404-3707
(319) 365-9164
(319) 365-6411
Mailing address
2309 C ST SW, CEDAR RAPIDS, IA 52404-3707
(319) 365-9164
(319) 365-6411
Taxonomy
Speciality
Code
Description
License number
State
323P00000X
Psychiatric Residential Treatment Facility
Primary
57PM-0005
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0047639
—
IA
Enumeration date
12/29/2006
Last updated
08/22/2020
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