Provider Demographics
NPI:1922590009
Name:BRENTWOOD SPRINGS DETOX
Entity Type:Organization
Organization Name:BRENTWOOD SPRINGS DETOX
Other - Org Name:BRENTWOOD SPRINGS DETOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGE CARE ADVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD CONNELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-209-5458
Mailing Address - Street 1:5935 EDMONDSON PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-6703
Mailing Address - Country:US
Mailing Address - Phone:662-209-5458
Mailing Address - Fax:
Practice Address - Street 1:5935 EDMONDSON PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211
Practice Address - Country:US
Practice Address - Phone:662-209-5458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000022121324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility