Provider Demographics
NPI:1023151354
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT 3
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-745-7350
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:ACCOUNTING DEPT
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-0586
Mailing Address - Country:US
Mailing Address - Phone:901-745-7350
Mailing Address - Fax:901-745-7433
Practice Address - Street 1:11293 MEMPHIS ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-7978
Practice Address - Country:US
Practice Address - Phone:901-745-7350
Practice Address - Fax:901-745-7433
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF TENNESSEE DBA ARLINGTON DEVELOPMENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-15
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN315P00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-7004OtherTENNCARE
TN7447006Medicaid
TN744-7006OtherTENNCARE
TN7447004Medicaid