Basic Information
| Provider Information | |||||||||
| NPI: | 1205011236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEPT. OF VETERANS AFFAIRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 LEBANON RD BLDG 11 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371291237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158676000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 LEBANON RD BLDG 11 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371291237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158676000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 01/09/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | BRODERICK | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADDICTION THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6158676000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | LDC0000000860 | TN | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
No ID Information.