Provider Demographics
NPI:1447618061
Name:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN
Entity Type:Organization
Organization Name:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES, STATE OF TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY COMMISSIONER, FINANCE & ADMI
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-253-6710
Mailing Address - Street 1:400 DEADERICK ST
Mailing Address - Street 2:9TH FLOOR, CITIZEN PLAZA BUILDING
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37243-1403
Mailing Address - Country:US
Mailing Address - Phone:615-532-6530
Mailing Address - Fax:
Practice Address - Street 1:400 DEADERICK ST
Practice Address - Street 2:9TH FLOOR, CITIZEN PLAZA BUILDING
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37243-1403
Practice Address - Country:US
Practice Address - Phone:615-532-6530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNW000002Medicaid