Provider Demographics
NPI:1588495766
Name:CEDAR RECOVERY OF MIDDLE TENNESSEE, LLC
Entity type:Organization
Organization Name:CEDAR RECOVERY OF MIDDLE TENNESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF STRATEGY OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-914-1518
Mailing Address - Street 1:5000 CROSSINGS CIR STE 103
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8591
Mailing Address - Country:US
Mailing Address - Phone:615-288-1103
Mailing Address - Fax:615-549-7044
Practice Address - Street 1:1512 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4825
Practice Address - Country:US
Practice Address - Phone:615-257-6844
Practice Address - Fax:615-549-7044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CEDAR RECOVERY OF MIDDLE TENNESSEE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ090493Medicaid