MEDICARE: PROFESSIONAL SERVICE GROUP PSG

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	251E00000X	Home Health Agency	1000000011801	TN

General Provider Information

NPI Number	:	1265776801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SERVICE GROUP PSG

Provider Business Mailing Address
First Line	:	200 W 38TH ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37410-1317
Country	:	US
Telephone Number	:	423-266-1384
Fax Number	:	423-756-3557

Provider Business Practice Location Address
First Line	:	200 W 38TH ST
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37410-1317
Country	:	US
Telephone Number	:	423-266-1384
Fax Number	:	423-756-3557

Authorized Official
Title or Position	:	OWNER/ CEO
Name	:	MR. LURONE JENNINGS SR.
Credential	:
Telephone Number	:	423-266-1384

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	11/20/2012

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