Provider Demographics
NPI:1134264450
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-421-6700
Mailing Address - Street 1:209 N BELLS STREET
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001
Mailing Address - Country:US
Mailing Address - Phone:731-696-2505
Mailing Address - Fax:731-696-4370
Practice Address - Street 1:209 N BELLS STREET
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001
Practice Address - Country:US
Practice Address - Phone:731-696-2505
Practice Address - Fax:731-696-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
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
TN4448026Medicaid
TN3911105Medicare ID - Type Unspecified