=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477966976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF TENNESSEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4850 E ANDREW JOHNSON HWY DIDD EAST TN SEATING AND POSITIONING CLINIC
-----------------------------------------------------
City | GREENEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37745-3098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-787-6689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 DEADERICK ST CITIZENS PLAZA, 10TH FLOOR
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37243-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-253-6710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEPUTY COMMISSIONER
-----------------------------------------------------
Name | MR. LANCE DEREK IVERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-253-6710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------