Provider Demographics
NPI:1699758722
Name:INTREPID OF TENNESSEE, INC.
Entity type:Organization
Organization Name:INTREPID OF TENNESSEE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUNYSZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:72 STONEBRIDGE
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2158
Practice Address - Country:US
Practice Address - Phone:731-668-9400
Practice Address - Fax:731-668-9498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000175251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
447565Medicare Oscar/Certification