Provider Demographics
NPI:1760534556
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:HUMPHREYS COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-650-7000
Mailing Address - Street 1:725 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-3284
Mailing Address - Country:US
Mailing Address - Phone:931-296-2231
Mailing Address - Fax:931-296-4590
Practice Address - Street 1:725 HOLLY LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-3284
Practice Address - Country:US
Practice Address - Phone:931-296-2231
Practice Address - Fax:931-296-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448022Medicaid
TN4448022Medicaid