Provider Demographics
NPI:1184262644
Name:TEN BROECK TENNESSEE PHYSICIANS
Entity type:Organization
Organization Name:TEN BROECK TENNESSEE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-783-2511
Mailing Address - Street 1:210 S JUDSON ST
Mailing Address - Street 2:
Mailing Address - City:NAVASOTA
Mailing Address - State:TX
Mailing Address - Zip Code:77868-3704
Mailing Address - Country:US
Mailing Address - Phone:936-870-4571
Mailing Address - Fax:936-870-4572
Practice Address - Street 1:210 S JUDSON ST
Practice Address - Street 2:
Practice Address - City:NAVASOTA
Practice Address - State:TX
Practice Address - Zip Code:77868-3704
Practice Address - Country:US
Practice Address - Phone:936-870-4571
Practice Address - Fax:936-870-4572
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEN BROECK TENNESSEE PHYSICIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)