Healthcare Provider Details

I. General information

NPI: 1689586695
Provider Name (Legal Business Name): TENNESSEE CENTER FOR TEENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 QUAD OAK DR
MOUNT JULIET TN
37122-6129
US

IV. Provider business mailing address

254 QUAD OAK DR
MOUNT JULIET TN
37122-6129
US

V. Phone/Fax

Practice location:
  • Phone: 949-620-6135
  • Fax:
Mailing address:
  • Phone: 615-488-7768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS CIES
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-488-7768