Basic Information
| Provider Information | |||||||||
| NPI: | 1750708798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VETERANS AFFAIRS HOSPITAL (MEMPHIS) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | DEPARTMENT OF MENTAL HEALTH/CHEMICAL DEPENDENCY CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | 9015777467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 JEFFERSON AVE | ||||||||
| Address2: | DEPARTMENT OF MENTAL HEALTH/CHEMICAL DEPENDENCY CENTER | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015238990 | ||||||||
| FaxNumber: | 9015777467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 03/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | KNIGHT | ||||||||
| AuthorizedOfficialFirstName: | C. | ||||||||
| AuthorizedOfficialMiddleName: | DIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9015777200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | LH0169 | MS | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.