Healthcare Provider Details

I. General information

NPI: 1649251299
Provider Name (Legal Business Name): COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 02/03/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E. SWAN ST
CENTERVILLE TN
37033
US

IV. Provider business mailing address

106 E. SWAN ST
CENTERVILLE TN
37033
US

V. Phone/Fax

Practice location:
  • Phone: 931-729-3004
  • Fax: 931-729-5528
Mailing address:
  • Phone: 931-729-3004
  • Fax: 931-729-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: DESTINY VAN METRE
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 270-744-8413