Provider Demographics
NPI:1447399837
Name:STATE OF TENNESSEE, GREENE VALLEY DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:STATE OF TENNESSEE, GREENE VALLEY DEVELOPMENTAL CENTER
Other - Org Name:GREEN VALLEY DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. CHIEF OFFICER FOR ADMIN.
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-787-6572
Mailing Address - Street 1:4850 E ANDREW JOHNSON HWY (37745-3098)
Mailing Address - Street 2:P.O. BOX 910
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37744-0910
Mailing Address - Country:US
Mailing Address - Phone:423-787-6800
Mailing Address - Fax:423-787-6975
Practice Address - Street 1:4850 E ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3098
Practice Address - Country:US
Practice Address - Phone:423-787-6800
Practice Address - Fax:423-787-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 323-106-1620315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-7014Medicaid