1699872879 NPI number — TRI-AGE ADVENTURES, INC.

Table of content: MRS. DESEREE MARIE HICKS RN, BSN (NPI 1932702073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699872879 NPI number — TRI-AGE ADVENTURES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-AGE ADVENTURES, INC.
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:
6
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:
1699872879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 TIMES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37083-1247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-666-3170
Provider Business Mailing Address Fax Number:
615-666-9146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 TIMES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37083-1247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-666-3170
Provider Business Practice Location Address Fax Number:
615-666-9146
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AUSTIN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
RUTH
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
615-666-3170

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  168 , 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: 0445410 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7440570 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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