Healthcare Provider Details

I. General information

NPI: 1649770769
Provider Name (Legal Business Name): FAST PACE MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4152 W STATE ROAD
HANOVER IN
47243
US

IV. Provider business mailing address

PO BOX 1258
WAYNESBORO TN
38485-1258
US

V. Phone/Fax

Practice location:
  • Phone: 931-253-1110
  • Fax: 931-722-9919
Mailing address:
  • Phone: 931-253-1110
  • Fax: 931-722-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT BENSON
Title or Position: COO
Credential:
Phone: 931-253-1110