Healthcare Provider Details

I. General information

NPI: 1174660039
Provider Name (Legal Business Name): STATE OF TENNESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 RIVERFRONT PKWY STE 209
CHATTANOOGA TN
37402-3312
US

IV. Provider business mailing address

1301 RIVERFRONT PKWY STE 209
CHATTANOOGA TN
37402-3312
US

V. Phone/Fax

Practice location:
  • Phone: 423-634-5832
  • Fax: 423-634-6087
Mailing address:
  • Phone: 423-634-3124
  • Fax: 423-634-6087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD W MCCARTHY
Title or Position: ACCOUNTING MANAGER
Credential:
Phone: 423-634-5832