MEDICARE: MID-TN SUPPORTED LIVING, INC.

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1568730554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-TN SUPPORTED LIVING, INC.

Provider Business Mailing Address
First Line	:	1161 MURFREESBORO RD
Second Line	:	SUITE 215
City	:	NASHVILLE
State	:	TN
Zip	:	37217-2222
Country	:	US
Telephone Number	:	615-367-0592
Fax Number	:	615-399-8407

Provider Business Practice Location Address
First Line	:	1161 MURFREESBORO RD
Second Line	:	SUITE 215
City	:	NASHVILLE
State	:	TN
Zip	:	37217-2222
Country	:	US
Telephone Number	:	615-367-0592
Fax Number	:	615-399-8407

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MICHELLE MCCAIN
Credential	:	MA
Telephone Number	:	615-367-0592

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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