Basic Information
| Provider Information | |||||||||
| NPI: | 1295898393 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE HEALTHCARE SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 UNION AVE | ||||||||
| Address2: | ALLIANCE HEALTHCARE SERVICES | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691420 | ||||||||
| FaxNumber: | 9013691433 | ||||||||
| Practice Location | |||||||||
| Address1: | 3810 WINCHESTER RD | ||||||||
| Address2: | SOUTHEAST MENTAL HEALTH CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381186045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013691420 | ||||||||
| FaxNumber: | 9013691433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | OWEN | ||||||||
| AuthorizedOfficialMiddleName: | EUGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9013691420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIANCE HEALTHCARE SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | L2140766278 | TN | N | Agencies | Case Management | 251B00000X | L2140766281 | TN | N | Agencies | Case Management | 251B00000X | L2140766280 | TN | N | Agencies | Case Management | 251B00000X | L2140766279 | TN | N | Agencies | Case Management | 251S00000X | 276 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | 269 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | L2140766281 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | L2140766280 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | L2140766279 | TN | N | Agencies | Community/Behavioral Health | 251S00000X | TN | N | Agencies | Community/Behavioral Health | 261QP2300X | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QP2300X | L18537 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 251S00000X | L2140766278 | TN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3399596 | 05 | TN | MEDICAID | 399596 | 05 | TN | MEDICAID |