1770588683 NPI number — GRUNDY COUNTY HEALTH SERVICES, 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 1770588683 NPI number — GRUNDY COUNTY HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRUNDY COUNTY HEALTH SERVICES, 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:
TRACY 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:
1770588683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 1449
Provider Business Mailing Address City Name:
TRACY CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37387-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-592-4242
Provider Business Mailing Address Fax Number:
931-592-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRACY CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37387-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-592-4242
Provider Business Practice Location Address Fax Number:
931-592-4245
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
YARWORTH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-592-4242

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN0000010476 , 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: Q078893 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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