Basic Information
| Provider Information | |||||||||
| NPI: | 1487839437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TENNESSEE VALLEY HEALTH CARE SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VETERAN'S ADMINISTRATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 LEBANON PIKE | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371291236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158931360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371291237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158931360 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADDICTION THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6158931360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CAC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 796A | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.