Provider Demographics
NPI:1104279330
Name:TELLURIAN, INC.
Entity type:Organization
Organization Name:TELLURIAN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-663-2120
Mailing Address - Street 1:414 BROADWAY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-2488
Mailing Address - Country:US
Mailing Address - Phone:608-402-4312
Mailing Address - Fax:608-355-0459
Practice Address - Street 1:414 BROADWAY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2488
Practice Address - Country:US
Practice Address - Phone:608-402-4312
Practice Address - Fax:608-355-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3127251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health