Healthcare Provider Details

I. General information

NPI: 1104839703
Provider Name (Legal Business Name): CROCKETT MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/01/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 S. BELLS ST
ALAMO TN
38001
US

IV. Provider business mailing address

58 S. BELLS ST
ALAMO TN
38001
US

V. Phone/Fax

Practice location:
  • Phone: 731-696-5401
  • Fax: 731-696-5404
Mailing address:
  • Phone: 731-696-5401
  • Fax: 731-696-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RITA CROOM
Title or Position: CFO
Credential:
Phone: 731-696-4670