Provider Demographics
NPI:1912928664
Name:STATE OF TENNESSEE
Entity Type:Organization
Organization Name:STATE OF TENNESSEE
Other - Org Name:METRO MOORE HEALTH FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-490-8334
Mailing Address - Street 1:251 MAJORS BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37352-8352
Mailing Address - Country:US
Mailing Address - Phone:931-759-4251
Mailing Address - Fax:931-759-6380
Practice Address - Street 1:251 MAJORS BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352-8352
Practice Address - Country:US
Practice Address - Phone:931-759-4251
Practice Address - Fax:931-759-6380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4448000Medicaid
TN0119549OtherBC/BS & TENNCARE SELECT
TN3065987OtherTENNCARE SELECT PCP
TN3910656Medicare ID - Type Unspecified
TN443819Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC (RHC)
TN0119549OtherBC/BS & TENNCARE SELECT