MEDICARE: CEDAR RECOVERY OF MIDDLE TENNESSEE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336L0003X	Long Term Care Pharmacy
2	3336C0002X	Clinic Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124861406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR RECOVERY OF MIDDLE TENNESSEE, LLC

Provider Business Mailing Address
First Line	:	5000 CROSSINGS CIR STE 103
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-8591
Country	:	US
Telephone Number	:	615-257-6844
Fax Number	:	615-549-7044

Provider Business Practice Location Address
First Line	:	2525 PERIMETER PLACE DR STE 105
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37214-3674
Country	:	US
Telephone Number	:	615-257-6844
Fax Number	:	615-549-7044

Authorized Official
Title or Position	:	CHIEF STRATEGY OFFICER
Name	:	PAUL STEPHEN TRIVETTE
Credential	:
Telephone Number	:	423-914-1518

Provider Enumeration Date	:	06/14/2024
Last Update Date	:	08/09/2024

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