Provider Demographics
NPI:1811159072
Name:STATE OF TENNESSEE GREENE VALLEY DEVELOPMENTAL CENTER
Entity type:Organization
Organization Name:STATE OF TENNESSEE GREENE VALLEY DEVELOPMENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL DIRECTOR 1
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIMCOX
Authorized Official - Suffix:
Authorized Official - Credentials:CPA CGFM
Authorized Official - Phone:423-787-6570
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37744-0910
Mailing Address - Country:US
Mailing Address - Phone:423-787-6570
Mailing Address - Fax:423-787-6975
Practice Address - Street 1:4850 E ANDREW JOHNSON HWY
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3098
Practice Address - Country:US
Practice Address - Phone:423-787-6570
Practice Address - Fax:423-787-6975
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF TENNESSEE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL3231061620315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447018Medicaid