Provider Demographics
NPI:1639623754
Name:PROVIDENCE COMPANION CARE OF TN 1, LLC
Entity Type:Organization
Organization Name:PROVIDENCE COMPANION CARE OF TN 1, LLC
Other - Org Name:PROVIDENCE COMPANION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-220-1266
Mailing Address - Street 1:600 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8226
Mailing Address - Country:US
Mailing Address - Phone:423-220-1266
Mailing Address - Fax:866-404-0950
Practice Address - Street 1:600 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 10
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8226
Practice Address - Country:US
Practice Address - Phone:423-220-1266
Practice Address - Fax:866-404-0950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000018767253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care