1811054521 NPI number — PROFESSIONAL CARE SERVICES OF WEST TN INC

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 1811054521 NPI number — PROFESSIONAL CARE SERVICES OF WEST TN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL CARE SERVICES OF WEST TN 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:
WM F WALKER COUNSELING CENTER
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:
1811054521
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1997 HIGHWAY 51 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38019-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-475-3586
Provider Business Mailing Address Fax Number:
901-476-2458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 COMMERCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIPLEY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38063-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-635-3968
Provider Business Practice Location Address Fax Number:
901-313-1125
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
901-622-1688

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0000002381 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2091668 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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