1891808853 NPI number — THE POUCH PLACE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891808853 NPI number — THE POUCH PLACE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE POUCH PLACE, 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:
1891808853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8805 KINGSTON PIKE
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37923-5017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-531-1285
Provider Business Mailing Address Fax Number:
865-690-0769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8805 KINGSTON PIKE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-5017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-531-1285
Provider Business Practice Location Address Fax Number:
865-690-0769
Provider Enumeration Date:
08/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
BERYL
Authorized Official Middle Name:
PRICE
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
865-531-1285

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3562662 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0138932 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".