Healthcare Provider Details

I. General information

NPI: 1285905976
Provider Name (Legal Business Name): STATE OF TENNESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 SUSONG RD
GREENEVILLE TN
37743-4944
US

IV. Provider business mailing address

315 DEADERICK ST FL 8
NASHVILLE TN
37238-3000
US

V. Phone/Fax

Practice location:
  • Phone: 423-787-0659
  • Fax:
Mailing address:
  • Phone:
  • Fax: 615-253-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberI000000010131
License Number StateTN

VIII. Authorized Official

Name: DAVID COMM
Title or Position: DIRECTOR OF BUSINESS SERVICES
Credential:
Phone: 629-267-8103