Provider Demographics
NPI:1093536658
Name:TAN, CIRE NICOLAS JUANICO
Entity type:Individual
Prefix:
First Name:CIRE NICOLAS
Middle Name:JUANICO
Last Name:TAN
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 1:870 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-1717
Mailing Address - Country:US
Mailing Address - Phone:224-518-3215
Mailing Address - Fax:
Practice Address - Street 1:870 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-1717
Practice Address - Country:US
Practice Address - Phone:224-518-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer