MEDICARE: INNOVATIVE FAMILY CARE, PLLC

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	207Q00000X	Family Medicine Physician	23607	TN

General Provider Information

NPI Number	:	1720345408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE FAMILY CARE, PLLC

Provider Business Mailing Address
First Line	:	3300 WILLIAMS ENTERPRISE DR
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-4280
Country	:	US
Telephone Number	:	931-528-9222
Fax Number	:	931-854-0907

Provider Business Practice Location Address
First Line	:	3300 WILLIAMS ENTERPRISE DR
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-4280
Country	:	US
Telephone Number	:	931-528-9222
Fax Number	:	931-854-0907

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LIBBY B PLUNKETT
Credential	:
Telephone Number	:	931-528-9222

Provider Enumeration Date	:	04/18/2012
Last Update Date	:	12/06/2022

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