Provider Demographics
NPI:1528470630
Name:REBECCA A. GRIGGS
Entity type:Organization
Organization Name:REBECCA A. GRIGGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-661-9163
Mailing Address - Street 1:21 SECURITY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3626
Mailing Address - Country:US
Mailing Address - Phone:731-661-9163
Mailing Address - Fax:731-664-9916
Practice Address - Street 1:21 SECURITY DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3626
Practice Address - Country:US
Practice Address - Phone:731-661-9163
Practice Address - Fax:731-664-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3642935Medicaid
TN3642935Medicaid