Provider Demographics
NPI:1467760876
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:DIDD EAST TN HOMES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EAST TN HOMES DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGI
Authorized Official - Middle Name:
Authorized Official - Last Name:STORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-787-6757
Mailing Address - Street 1:190 SERRAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-3074
Mailing Address - Country:US
Mailing Address - Phone:423-787-6757
Mailing Address - Fax:423-798-6253
Practice Address - Street 1:855 MEADOWBROOK RD
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:TN
Practice Address - Zip Code:37616-6047
Practice Address - Country:US
Practice Address - Phone:423-787-6757
Practice Address - Fax:423-798-6253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447148Medicaid