Provider Demographics
NPI:1760602338
Name:TIMOTHY STREET
Entity Type:Organization
Organization Name:TIMOTHY STREET
Other - Org Name:T L C MEDICAL TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRANSPORTATION VENDOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-895-0425
Mailing Address - Street 1:204 OLD SIAM RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-895-0425
Mailing Address - Fax:423-543-7707
Practice Address - Street 1:204 OLD SIAM RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-895-0425
Practice Address - Fax:423-543-7707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN052488290172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT000186Medicaid