1518106020 NPI number — TIDWELL FAMILY VENTURES LLC

Table of content: (NPI 1518106020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518106020 NPI number — TIDWELL FAMILY VENTURES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIDWELL FAMILY VENTURES LLC
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:
PORTLAND FAMILY CARE AND WALK-IN CLINIC
Provider Other Organization Name Type Code:
3
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:
1518106020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 S BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37148-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-323-1020
Provider Business Mailing Address Fax Number:
615-323-1021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37148-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-323-1020
Provider Business Practice Location Address Fax Number:
615-323-1021
Provider Enumeration Date:
02/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TIDWELL
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
615-323-1020

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1755 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 10971 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 13982 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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