MEDICARE: STATE OF TENNESSEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility

General Provider Information

NPI Number	:	1306081427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF TENNESSEE

Provider Business Mailing Address
First Line	:	11437 MILTON WILSON ROAD
Second Line	:
City	:	ARLINGTON
State	:	TN
Zip	:	38002-0000
Country	:	US
Telephone Number	:	901-745-7357
Fax Number	:	901-745-7251

Provider Business Practice Location Address
First Line	:	11437 MILTON WILSON ROAD
Second Line	:
City	:	ARLINGTON
State	:	TN
Zip	:	38002-0000
Country	:	US
Telephone Number	:	901-745-7357
Fax Number	:	901-745-7251

Authorized Official
Title or Position	:	REGIONAL DIRECTOR
Name	:	MS. C. J. MCMORRAN
Credential	:	OTR, MBA
Telephone Number	:	901-745-7357

Provider Enumeration Date	:	12/03/2008
Last Update Date	:	04/15/2010

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Directions to “STATE OF TENNESSEE ” Practice Location

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