1063575165 NPI number — SOUTHEAST MENTAL HEALTH CENTER, INC

Table of content: (NPI 1063575165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063575165 NPI number — SOUTHEAST MENTAL HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST MENTAL HEALTH CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063575165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3810 WINCHESTER RD
Provider Second Line Business Mailing Address:
SOUTHEAST MENTAL HEALTH CENTER
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38118-6045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-369-1420
Provider Business Mailing Address Fax Number:
901-369-1433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2579 DOUGLASS AVE
Provider Second Line Business Practice Location Address:
SOUTHEAST MENTAL HEALTH CENTER
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38114-2532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-369-1484
Provider Business Practice Location Address Fax Number:
901-312-7572
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENCE
Authorized Official First Name:
OWEN
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
901-369-1420

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  762 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 399596 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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