Provider Demographics
NPI:1417960733
Name:COLUMBIA MEDICAL GROUPDAYSTAR INC
Entity Type:Organization
Organization Name:COLUMBIA MEDICAL GROUPDAYSTAR INC
Other - Org Name:DAYSTAR COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:TULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:423-744-8734
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-0867
Mailing Address - Country:US
Mailing Address - Phone:423-744-8734
Mailing Address - Fax:423-649-0346
Practice Address - Street 1:748 TELL STREET
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303
Practice Address - Country:US
Practice Address - Phone:423-744-8734
Practice Address - Fax:423-649-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711666Medicare PIN