1760759617 NPI number — CONVIENENT CARE CLINIC

Table of content: (NPI 1760759617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760759617 NPI number — CONVIENENT CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONVIENENT CARE 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:
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:
1760759617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2490 PARR AVE
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
DYERSBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38024-2029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-286-8007
Provider Business Mailing Address Fax Number:
731-286-8019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2490 PARR AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYERSBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38024-2029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-286-8007
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCCALLUM
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
731-445-9406

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  13555 , 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: Q008468 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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