=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447578018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENNESSEE RIVER PAIN MANAGEMENT CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2010
-----------------------------------------------------
Last Update Date | 08/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275A EUREKA ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-7246
-----------------------------------------------------
Fax | 731-925-7991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275A EUREKA ST
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP
-----------------------------------------------------
Name | MS. TERESA DIANE DAILEY
-----------------------------------------------------
Credential | NP, MSN
-----------------------------------------------------
Telephone | 731-925-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 13057
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------