Provider Demographics
NPI:1467723155
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-267-8103
Mailing Address - Street 1:315 DEADERICK ST FL 8
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37238-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:615-253-6713
Practice Address - Street 1:2107 SUSONG RD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-4944
Practice Address - Country:US
Practice Address - Phone:423-787-0673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
TNI000000010134315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447173Medicaid