1689603532 NPI number — CHEROKEE HEALTH CARE SUPPLY INC

Table of content: (NPI 1689603532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689603532 NPI number — CHEROKEE HEALTH CARE SUPPLY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHEROKEE HEALTH CARE SUPPLY 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:
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:
1689603532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1690 25TH ST NW
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37311-3613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-559-3010
Provider Business Mailing Address Fax Number:
423-559-3011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1690 25TH ST NW
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37311-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-559-3010
Provider Business Practice Location Address Fax Number:
423-559-3011
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FORSHEE
Authorized Official First Name:
RICKY
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
423-559-3010

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  673 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BX2000X , with the licence number: 673 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00356452C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0049062 . This is a "BCBS/TENNCARE PROV #" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 00195742B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3536528 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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