Provider Demographics
NPI:1396983276
Name:STATE OF TENNESSEE
Entity type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ORISTYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:731-426-0686
Mailing Address - Street 1:295 SUMMAR DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3905
Mailing Address - Country:US
Mailing Address - Phone:731-426-0686
Mailing Address - Fax:731-421-5199
Practice Address - Street 1:295 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3905
Practice Address - Country:US
Practice Address - Phone:731-426-0686
Practice Address - Fax:731-421-5199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TENNESSEE DEPARTMENT OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-30
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000002293291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory