Provider Demographics
NPI:1720694193
Name:DETOX WEST TENNESSEE LLC
Entity Type:Organization
Organization Name:DETOX WEST TENNESSEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-969-8612
Mailing Address - Street 1:370 N CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 N CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5470
Practice Address - Country:US
Practice Address - Phone:615-969-8612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN971960OtherDOB