1063605681 NPI number — ADAMSVILLE HEALTHCARE LLC

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 1063605681 NPI number — ADAMSVILLE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADAMSVILLE HEALTHCARE LLC
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:
TRI COUNTY HEALTHCARE 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:
1063605681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 325
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADAMSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38310-0325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-632-3301
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADAMSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38310-2461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-632-3301
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK DANKS
Authorized Official First Name:
ALICE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
VP OF FINANCE
Authorized Official Telephone Number:
423-308-1845

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0144 , 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: 0445397 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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