MEDICARE: COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE

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	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	709849100	OTHER	TN	DOL - FECA / BL / ENERGY
3	4110080	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1649251299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE

Provider Business Mailing Address
First Line	:	106 E. SWAN ST
Second Line	:
City	:	CENTERVILLE
State	:	TN
Zip	:	37033
Country	:	US
Telephone Number	:	931-729-3004
Fax Number	:	931-729-5528

Provider Business Practice Location Address
First Line	:	106 E. SWAN ST
Second Line	:
City	:	CENTERVILLE
State	:	TN
Zip	:	37033
Country	:	US
Telephone Number	:	931-729-3004
Fax Number	:	931-729-5528

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT
Name	:	DESTINY VAN METRE
Credential	:
Telephone Number	:	270-744-8413

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	02/03/2023

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Directions to “COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE ” Practice Location

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