1194923029 NPI number — LOBELVILLE CLINIC

Table of content: (NPI 1194923029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194923029 NPI number — LOBELVILLE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOBELVILLE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KENNETH SALHANY DBA LOBELVILLE CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194923029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 219
Provider Second Line Business Mailing Address:
236 NORTH MAIN ST.
Provider Business Mailing Address City Name:
LOBELVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37097-0219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-593-2277
Provider Business Mailing Address Fax Number:
931-593-2517

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
236 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOBELVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-593-2277
Provider Business Practice Location Address Fax Number:
931-593-2517
Provider Enumeration Date:
07/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CUNNINGHAM
Authorized Official First Name:
BECKY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MGR.
Authorized Official Telephone Number:
931-593-2277

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3303612 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".