Provider Demographics
NPI:1427030907
Name:CHURCH HEALTH CENTER OF MEMPHIS INC
Entity Type:Organization
Organization Name:CHURCH HEALTH CENTER OF MEMPHIS INC
Other - Org Name:CHURCH HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MUNGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-272-0003
Mailing Address - Street 1:PO BOX 41527
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38174-1527
Mailing Address - Country:US
Mailing Address - Phone:901-272-0003
Mailing Address - Fax:901-725-1435
Practice Address - Street 1:1200 PEABODY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4506
Practice Address - Country:US
Practice Address - Phone:901-272-0003
Practice Address - Fax:901-725-1435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3388963OtherTENNCARE TLC
TN3388963Medicaid
TN3388963Medicaid