MEDICARE: COFFEE MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1407431943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COFFEE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	481 INTERSTATE DR
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-3108
Country	:	US
Telephone Number	:	931-450-1109
Fax Number	:

Provider Business Practice Location Address
First Line	:	6290 MANCHESTER HWY
Second Line	:
City	:	MORRISON
State	:	TN
Zip	:	37357-7589
Country	:	US
Telephone Number	:	931-128-6354
Fax Number	:

Authorized Official
Title or Position	:	REVENUE CYCLE DIRECTOR
Name	:	DOUG MCABEE
Credential	:
Telephone Number	:	931-450-1109

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	03/16/2021

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Directions to “COFFEE MEDICAL GROUP LLC ” Practice Location

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