Healthcare Provider Details

I. General information

NPI: 1083767883
Provider Name (Legal Business Name): STATE OF TENNESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 SPRING ST
DOVER TN
37058-3302
US

IV. Provider business mailing address

1021 SPRING ST
DOVER TN
37058-3302
US

V. Phone/Fax

Practice location:
  • Phone: 931-232-5329
  • Fax: 931-232-7247
Mailing address:
  • Phone: 931-232-5329
  • Fax: 931-232-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateTN

VIII. Authorized Official

Name: MR. ANNETTE M. HALEY
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 615-650-7000