1760926075 NPI number — COFFEE ASSOCIATES A MEDICAL MANAGEMENT ORGANIZATION, LLC

Table of content: (NPI 1760926075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760926075 NPI number — COFFEE ASSOCIATES A MEDICAL MANAGEMENT ORGANIZATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COFFEE ASSOCIATES A MEDICAL MANAGEMENT ORGANIZATION, 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:
Provider Other Organization Name Type Code:
6
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:
1760926075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
482 INTERSTATE DR
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37355-3485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-444-1000
Provider Business Mailing Address Fax Number:
931-450-8256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
482 INTERSTATE DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37355-3485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-444-1000
Provider Business Practice Location Address Fax Number:
931-450-8256
Provider Enumeration Date:
12/06/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CHESTER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
CLIFTON
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
931-444-1000

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3079 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LSW000000003614 , 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)





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