Healthcare Provider Details

I. General information

NPI: 1598292344
Provider Name (Legal Business Name): 180 R.E.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 E MAIN ST STE 3
HENDERSONVILLE TN
37075-2645
US

IV. Provider business mailing address

2551 ELKMONT DR
CLARKSVILLE TN
37040-2866
US

V. Phone/Fax

Practice location:
  • Phone: 931-220-1384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JEREMY LYNCH
Title or Position: CEO
Credential:
Phone: 931-220-1384