1396801007 NPI number — PROFESSIONAL CARE SERVICES OF WEST TN INC

Table of content: (NPI 1396801007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396801007 NPI number — PROFESSIONAL CARE SERVICES OF WEST TN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL CARE SERVICES OF WEST TN 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:
JB SUMMERS COUNSELING CENTER
Provider Other Organization Name Type Code:
3
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:
1396801007
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:
1997 HWY 51 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38019-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-476-8967
Provider Business Mailing Address Fax Number:
901-318-1125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12615 S MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38068-1673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-465-9831
Provider Business Practice Location Address Fax Number:
901-465-8070
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CAUSEY
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
901-476-8967

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  2382 , 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: 4428252 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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