Provider Demographics
NPI:1649251299
Name:COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE
Entity type:Organization
Organization Name:COUNTY OF HICKMAN OFFICE OF COUNTY EXECUTIVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DESTINY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN METRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-744-8413
Mailing Address - Street 1:106 E. SWAN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033
Mailing Address - Country:US
Mailing Address - Phone:931-729-3004
Mailing Address - Fax:931-729-5528
Practice Address - Street 1:106 E. SWAN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033
Practice Address - Country:US
Practice Address - Phone:931-729-3004
Practice Address - Fax:931-729-5528
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF HICKMAN OFFICE OF COUNTY EXEC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-10
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3416L0300X
TNEMS0000004101341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3525528Medicaid
TN709849100OtherDOL - FECA / BL / ENERGY
TN4110080OtherBCBS