Provider Demographics
NPI:1346087053
Name:MATHIS, TARA EUGENIA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:EUGENIA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20200 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-9432
Mailing Address - Country:US
Mailing Address - Phone:574-367-0395
Mailing Address - Fax:
Practice Address - Street 1:1657 COMMERCE DR STE 8B
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-1542
Practice Address - Country:US
Practice Address - Phone:574-367-0395
Practice Address - Fax:844-894-8398
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN61-1857998Medicaid
IN61-1857998OtherINTERNAL REVENUE SERVICES