Provider Demographics
NPI:1386895027
Name:COMMUNITY GOVERNING BOARD OF MATTEW WALKER COMPREHENSIVE CENTE
Entity type:Organization
Organization Name:COMMUNITY GOVERNING BOARD OF MATTEW WALKER COMPREHENSIVE CENTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-340-1292
Mailing Address - Street 1:1035 14TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-3050
Mailing Address - Country:US
Mailing Address - Phone:615-327-9400
Mailing Address - Fax:615-327-2806
Practice Address - Street 1:904 26TH AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-3202
Practice Address - Country:US
Practice Address - Phone:615-327-9400
Practice Address - Fax:615-327-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT07209AMedicaid