1104366988 NPI number — NEIGHBORHOOD CLINIC, PLLC

Table of content: (NPI 1104366988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104366988 NPI number — NEIGHBORHOOD CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEIGHBORHOOD CLINIC, PLLC
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:
Provider Other Organization Name Type Code:
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:
1104366988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1190 PETTIJOHN CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENRY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38231-4123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-499-2319
Provider Business Mailing Address Fax Number:
866-670-8568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 N BREWER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38242-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-415-3574
Provider Business Practice Location Address Fax Number:
731-240-0232
Provider Enumeration Date:
02/28/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PROSSER
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
731-499-2319

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN7205 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q026850 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com