1043975402 NPI number — FAST PACE MEDICAL CLINIC PLLC

Table of content: JONATHAN HENDERSON (NPI 1598113821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043975402 NPI number — FAST PACE MEDICAL CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAST PACE MEDICAL CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1043975402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306244
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37230-6244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41357 US HIGHWAY 280
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SYLACAUGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35150-8046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-531-1109
Provider Business Practice Location Address Fax Number:
317-229-9199
Provider Enumeration Date:
11/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CLEMMONS
Authorized Official First Name:
SYDNI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
901-351-1791

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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