=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942352554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF TENNESSEE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 OLD MCMINNVILLE ST
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38585-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-946-2438
-----------------------------------------------------
Fax | 931-946-7106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 ENGLAND DRIVE
-----------------------------------------------------
City | COOKEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38501-0924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-520-4201
-----------------------------------------------------
Fax | 931-520-3871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TAMMY STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-520-4203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------