Provider Demographics
NPI:1063786648
Name:TENNESSEE PHS PC
Entity type:Organization
Organization Name:TENNESSEE PHS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-991-9276
Mailing Address - Street 1:1509 DULLES DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-991-9288
Practice Address - Street 1:950 W. BANNOCK STREET
Practice Address - Street 2:SUITE 1100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6140
Practice Address - Country:US
Practice Address - Phone:877-260-4747
Practice Address - Fax:901-261-4867
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDER HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-29
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1063786648Medicaid
ID20000842Medicare PIN