1639623754 NPI number — PROVIDENCE COMPANION CARE OF TN 1, LLC

Table of content: (NPI 1639623754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639623754 NPI number — PROVIDENCE COMPANION CARE OF TN 1, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE COMPANION CARE OF TN 1, 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:
PROVIDENCE COMPANION CARE
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:
1639623754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 N STATE OF FRANKLIN RD
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-8226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-220-1266
Provider Business Mailing Address Fax Number:
866-404-0950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N STATE OF FRANKLIN RD
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-8226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-220-1266
Provider Business Practice Location Address Fax Number:
866-404-0950
Provider Enumeration Date:
08/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SIMPSON
Authorized Official First Name:
HUNTER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
423-220-1266

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  I000000018767 , 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)