1699795468 NPI number — STATE OF TENNESSEE

Table of content: (NPI 1699795468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699795468 NPI number — STATE OF TENNESSEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF TENNESSEE
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:
COFFEE COUNTY HEALTH DEPT. - TULLAHOMA CLINIC
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:
1699795468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 WILSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULLAHOMA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37388-3264
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-455-9369
Provider Business Mailing Address Fax Number:
931-455-4827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 WILSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULLAHOMA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37388-3264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-455-9369
Provider Business Practice Location Address Fax Number:
931-455-4827
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITWELL
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE SUPERVISOR
Authorized Official Telephone Number:
931-490-8334

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2002854 . This is a "BC/BS & TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4448008 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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