Provider Demographics
NPI:1447578018
Name:TENNESSEE RIVER PAIN MANAGEMENT CLINIC
Entity Type:Organization
Organization Name:TENNESSEE RIVER PAIN MANAGEMENT CLINIC
Other - Org Name:TENNESSEE RIVER PAIN MANAGEMENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:DAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:NP, MSN
Authorized Official - Phone:731-925-7246
Mailing Address - Street 1:275A EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-3033
Mailing Address - Country:US
Mailing Address - Phone:731-925-7246
Mailing Address - Fax:
Practice Address - Street 1:275A EUREKA ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-3033
Practice Address - Country:US
Practice Address - Phone:731-925-7246
Practice Address - Fax:731-925-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-06
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13057363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID