1811952062 NPI number — J.W. CARELL ENTERPRISES, LLC

Table of content: (NPI 1811952062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811952062 NPI number — J.W. CARELL ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J.W. CARELL ENTERPRISES, 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:
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:
1811952062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HOBSON ST
Provider Second Line Business Mailing Address:
STE 44
Provider Business Mailing Address City Name:
MCMINNVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37110-1671
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-473-9556
Provider Business Mailing Address Fax Number:
931-474-1910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HOBSON ST
Provider Second Line Business Practice Location Address:
STE 44
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37110-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-473-9556
Provider Business Practice Location Address Fax Number:
931-474-1910
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARELL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
615-781-0666

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  0000000265 , 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: A3711001 . This is a "AMERICHOICE PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01-035023 . This is a "AMERIGROUP COMMUNITY CARIE PROVIDER ID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4167951 . This is a "BC/BS PROVIDER ID" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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