Healthcare Provider Details

I. General information

NPI: 1356448633
Provider Name (Legal Business Name): TN VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 NEAL ST SUITE 101
COOKEVILLE TN
38501-0901
US

IV. Provider business mailing address

PO BOX 3432
COOKEVILLE TN
38502-3432
US

V. Phone/Fax

Practice location:
  • Phone: 931-525-1651
  • Fax: 931-525-2165
Mailing address:
  • Phone: 931-525-1651
  • Fax: 931-525-1653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number0000046089
License Number StateTN

VIII. Authorized Official

Name: DR. REXFORD AGBENOHEVI
Title or Position: MD
Credential: MD
Phone: 931-525-1651