Provider Demographics
NPI:1659919108
Name:TEN BROECK TENNESSEE PHYSICIANS
Entity Type:Organization
Organization Name:TEN BROECK TENNESSEE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-783-2511
Mailing Address - Street 1:100 W CROSS ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864-2432
Mailing Address - Country:US
Mailing Address - Phone:936-349-1671
Mailing Address - Fax:936-349-1672
Practice Address - Street 1:100 W CROSS ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-2432
Practice Address - Country:US
Practice Address - Phone:936-349-1671
Practice Address - Fax:936-349-1672
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEN BROECK TENNESSEE PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)