=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568730554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-TN SUPPORTED LIVING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2011
-----------------------------------------------------
Last Update Date | 12/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1161 MURFREESBORO RD SUITE 215
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37217-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-367-0592
-----------------------------------------------------
Fax | 615-399-8407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1161 MURFREESBORO RD SUITE 215
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37217-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-367-0592
-----------------------------------------------------
Fax | 615-399-8407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MICHELLE MCCAIN
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 615-367-0592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------