Provider Demographics
NPI:1538979331
Name:LALICH, TANNER
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:LALICH
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 1:12677 CROWN POINT AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1368
Mailing Address - Country:US
Mailing Address - Phone:402-672-2361
Mailing Address - Fax:
Practice Address - Street 1:9910 N 48TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-1548
Practice Address - Country:US
Practice Address - Phone:402-672-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant