Provider Demographics
NPI:1760926075
Name:COFFEE ASSOCIATES A MEDICAL MANAGEMENT ORGANIZATION, LLC
Entity Type:Organization
Organization Name:COFFEE ASSOCIATES A MEDICAL MANAGEMENT ORGANIZATION, LLC
Other - Org Name:RAPHA CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:CHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MHSP
Authorized Official - Phone:931-444-1000
Mailing Address - Street 1:482 INTERSTATE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3485
Mailing Address - Country:US
Mailing Address - Phone:931-444-1000
Mailing Address - Fax:931-450-8256
Practice Address - Street 1:482 INTERSTATE DR
Practice Address - Street 2:SUITE D
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3485
Practice Address - Country:US
Practice Address - Phone:931-444-1000
Practice Address - Fax:931-450-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3079101YP2500X
TNLSW0000000036141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty