1063786648 NPI number — TENNESSEE PHS PC

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 1063786648 NPI number — TENNESSEE PHS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENNESSEE PHS PC
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:
1063786648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1509 DULLES DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-991-9276
Provider Business Mailing Address Fax Number:
337-991-9288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 W. BANNOCK STREET
Provider Second Line Business Practice Location Address:
SUITE 1100
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83702-6140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-260-4747
Provider Business Practice Location Address Fax Number:
901-261-4867
Provider Enumeration Date:
02/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOWARD
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
337-991-9276

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063786648 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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