Provider Demographics
NPI:1164625828
Name:MID STATE ENT, LLC
Entity Type:Organization
Organization Name:MID STATE ENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:B
Authorized Official - Last Name:DEMOVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-822-2177
Mailing Address - Street 1:107 GLEN OAK BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075
Mailing Address - Country:US
Mailing Address - Phone:615-822-2177
Mailing Address - Fax:615-822-0300
Practice Address - Street 1:107 GLEN OAK BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075
Practice Address - Country:US
Practice Address - Phone:615-822-2177
Practice Address - Fax:615-822-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty