Provider Demographics
NPI:1205247699
Name:ICP TENNESSEE, LLC
Entity type:Organization
Organization Name:ICP TENNESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-498-6767
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:855-498-6767
Mailing Address - Fax:
Practice Address - Street 1:200 PROSPERITY PLACE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923
Practice Address - Country:US
Practice Address - Phone:855-498-6767
Practice Address - Fax:479-968-1673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty