Provider Demographics
NPI:1538114020
Name:STATE OF TENNESSEE-WESTERN MENTAL HEALTH INSTITUTE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE-WESTERN MENTAL HEALTH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-228-2044
Mailing Address - Street 1:11100 HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1554
Mailing Address - Country:US
Mailing Address - Phone:731-228-2000
Mailing Address - Fax:731-658-9822
Practice Address - Street 1:11100 HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1554
Practice Address - Country:US
Practice Address - Phone:731-228-2000
Practice Address - Fax:731-658-9822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL216-075-1114283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10796/2003053OtherBLUE CROSS/BLUE SHIELD
TN444008/3282236Medicaid
TN444008Medicare ID - Type Unspecified