Provider Demographics
NPI:1366009961
Name:TAHOMA ENTERPRISES LLC
Entity type:Organization
Organization Name:TAHOMA ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALENA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-765-8585
Mailing Address - Street 1:1648 SOUTHLAWN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8971
Mailing Address - Country:US
Mailing Address - Phone:616-633-7414
Mailing Address - Fax:
Practice Address - Street 1:1346 BALDWIN ST # 13
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8937
Practice Address - Country:US
Practice Address - Phone:616-765-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAHOMA ENTERPRISES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-20
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty