MEDICARE: TRANQUIL JC, LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1316552060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANQUIL JC, LLC

Provider Business Mailing Address
First Line	:	3113 INDIAN RIDGE RD
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2339
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 S ROAN ST STE 212
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-7557
Country	:	US
Telephone Number	:	423-430-9362
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	REBECCA DELONG
Credential	:
Telephone Number	:	423-430-9362

Provider Enumeration Date	:	09/10/2020
Last Update Date	:	09/10/2020

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