1689601809 NPI number — NUTRITIONAL SUPPORT SERVICES

Table of content: (NPI 1689601809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689601809 NPI number — NUTRITIONAL SUPPORT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NUTRITIONAL SUPPORT SERVICES
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:
1689601809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 32249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37930-2249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-690-9900
Provider Business Mailing Address Fax Number:
865-531-7016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 EXECUTIVE PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE A 301
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37923-4656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-690-9900
Provider Business Practice Location Address Fax Number:
865-531-7016
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEEMAN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
865-690-9900

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112948716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30762373 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3545979 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DM0001 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 622293603 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00571986A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209086400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100010580A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10MF49 . This is a "ALLIANCE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 90262056 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1354317 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40111 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 073622502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100002960A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9143513 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009000730 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01305375 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7611272 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80966900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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