Provider Demographics
NPI:1578276317
Name:TENNESSEE DETOX CENTER LLC
Entity Type:Organization
Organization Name:TENNESSEE DETOX CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-797-1407
Mailing Address - Street 1:509 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-5204
Mailing Address - Country:US
Mailing Address - Phone:817-797-1407
Mailing Address - Fax:
Practice Address - Street 1:509 LAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-5204
Practice Address - Country:US
Practice Address - Phone:817-797-1407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility