Provider Demographics
NPI:1467538009
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:LAKESHORE MENTAL HEALTH INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER - CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-583-8888
Mailing Address - Street 1:5908 LYONS VIEW PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919
Mailing Address - Country:US
Mailing Address - Phone:865-584-1561
Mailing Address - Fax:865-450-5203
Practice Address - Street 1:5908 LYONS VIEW PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919
Practice Address - Country:US
Practice Address - Phone:865-584-1561
Practice Address - Fax:865-450-5203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL2161051102283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0444000Medicaid
TN3282144OtherCIGNA MEDICARE PART B
TN0010800OtherBCBS
103G709065Medicare PIN
TN444000Medicare ID - Type Unspecified