Provider Demographics
NPI:1689601809
Name:NUTRITIONAL SUPPORT SERVICES
Entity Type:Organization
Organization Name:NUTRITIONAL SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-690-9900
Mailing Address - Street 1:PO BOX 32249
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2249
Mailing Address - Country:US
Mailing Address - Phone:865-690-9900
Mailing Address - Fax:865-531-7016
Practice Address - Street 1:9000 EXECUTIVE PARK DRIVE
Practice Address - Street 2:SUITE A 301
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4656
Practice Address - Country:US
Practice Address - Phone:865-690-9900
Practice Address - Fax:865-531-7016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112948716Medicaid
NH30762373Medicaid
TN3545979Medicaid
SCDM0001Medicaid
MO622293603Medicaid
GA00571986AMedicaid
FL209086400Medicaid
IN100010580AMedicaid
10MF49OtherALLIANCE BCBS
KY90262056Medicaid
LA1354317Medicaid
MS40111Medicaid
TX073622502Medicaid
KS100002960AMedicaid
VA9143513Medicaid
AL009000730Medicaid
NY01305375Medicaid
MN7611272Medicaid
WI80966900Medicaid
MN7611272Medicaid