Provider Demographics
NPI:1205005097
Name:SALLIE EARLY HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:SALLIE EARLY HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SALLIE
Authorized Official - Middle Name:EARLY
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:865-558-1584
Mailing Address - Street 1:1802 NEVA CT
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-1026
Mailing Address - Country:US
Mailing Address - Phone:865-588-1584
Mailing Address - Fax:
Practice Address - Street 1:1802 NEVA CT
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-1026
Practice Address - Country:US
Practice Address - Phone:865-588-1584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000007667164W00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3714700Medicaid
TN3714700Medicare PIN