Provider Demographics
NPI:1871643031
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:LAKE COUNTY HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-421-6700
Mailing Address - Street 1:400 HWY 78 SOUTH
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079
Mailing Address - Country:US
Mailing Address - Phone:731-253-9954
Mailing Address - Fax:731-253-9956
Practice Address - Street 1:400 HWY 78 SOUTH
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079
Practice Address - Country:US
Practice Address - Phone:731-253-9954
Practice Address - Fax:731-253-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448142Medicaid
TN4448142Medicaid