=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023151354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF TENNESSEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2007
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11293 MEMPHIS ARLINGTON RD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-7978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-745-7350
-----------------------------------------------------
Fax | 901-745-7433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 586 ACCOUNTING DEPT
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-0586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-745-7350
-----------------------------------------------------
Fax | 901-745-7433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT 3
-----------------------------------------------------
Name | MR. JOHN M. HASTINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-745-7350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------