1275650434 NPI number — CANCER CARE CENTER OF HENRY COUNTY, LLC

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 1275650434 NPI number — CANCER CARE CENTER OF HENRY COUNTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER CARE CENTER OF HENRY COUNTY, 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:
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:
1275650434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 HOSPITAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38305-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-668-1668
Provider Business Mailing Address Fax Number:
731-668-5801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 KELLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38242-4745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-644-3522
Provider Business Practice Location Address Fax Number:
731-644-2806
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAIN HARDIN
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
731-668-1668

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3720631 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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