Healthcare Provider Details

I. General information

NPI: 1821148081
Provider Name (Legal Business Name): STATE OF TENNESSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 NORTH 12TH STREET
HUMBOLDT TN
38343
US

IV. Provider business mailing address

149 NORTH 12TH STREET
HUMBOLDT TN
38343
US

V. Phone/Fax

Practice location:
  • Phone: 731-784-5491
  • Fax: 731-784-1726
Mailing address:
  • Phone: 731-784-5491
  • Fax: 731-784-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4448184
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name: MRS. MARILYN BARNES
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 731-421-6700