MEDICARE: LANTERN LANE FARM

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	1041C0700X	Clinical Social Worker	5836	TN

General Provider Information

NPI Number	:	1952726036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANTERN LANE FARM

Provider Business Mailing Address
First Line	:	6201 CORINTH RD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-7603
Country	:	US
Telephone Number	:	615-584-6959
Fax Number	:

Provider Business Practice Location Address
First Line	:	6201 CORINTH RD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-7603
Country	:	US
Telephone Number	:	615-584-6959
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. RALPH COOK
Credential	:	LMFT
Telephone Number	:	615-584-6959

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	02/26/2014

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