Basic Information
Provider Information
NPI: 1639515646
EntityType: 2
ReplacementNPI:  
OrganizationName: VCPHCS XIX, LLC
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Mailing Information
Address1: 5001 SPRING VALLEY ROAD
Address2: SUITE 600 EAST
City: DALLAS
State: TX
PostalCode: 752443946
CountryCode: US
TelephoneNumber: 2143656100
FaxNumber: 2143656150
Practice Location
Address1: 1869 HIGHWAY 45 BYP
Address2: SUITE 5
City: JACKSON
State: TN
PostalCode: 383052464
CountryCode: US
TelephoneNumber: 7316600880
FaxNumber: 7316680380
Other Information
ProviderEnumerationDate: 05/16/2013
LastUpdateDate: 02/20/2019
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AuthorizedOfficialLastName: GASAWAY
AuthorizedOfficialFirstName: JEMECE
AuthorizedOfficialMiddleName: MICHELLE
AuthorizedOfficialTitleorPosition: DIRECTOR OF LICENSING
AuthorizedOfficialTelephone: 2143656126
IsSoleProprietor:  
IsOrganizationSubpart: N
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM0801X  N Ambulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
261QM2800XL000000011853TNN Ambulatory Health Care FacilitiesClinic/CenterMethadone Clinic
261QR0405X  Y Ambulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder

No ID Information.


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