Provider Demographics
NPI:1306364054
Name:CG OF TENNESSEE, LLC
Entity Type:Organization
Organization Name:CG OF TENNESSEE, LLC
Other - Org Name:OMNI SUPPORT SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-447-2700
Mailing Address - Street 1:4800 OVERTON PLZ STE 440
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4435
Mailing Address - Country:US
Mailing Address - Phone:800-299-5161
Mailing Address - Fax:
Practice Address - Street 1:301 S PERIMETER PARK DR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4143
Practice Address - Country:US
Practice Address - Phone:615-832-5454
Practice Address - Fax:615-837-5772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000X
TNPENDING320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid