Healthcare Provider Details

I. General information

NPI: 1265771281
Provider Name (Legal Business Name): SOUTHERN CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 HIGHWAY 11W
BEAN STATION TN
37708-5809
US

IV. Provider business mailing address

PO BOX 280
BEAN STATION TN
37708-0280
US

V. Phone/Fax

Practice location:
  • Phone: 865-898-8318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number13557
License Number StateTN

VIII. Authorized Official

Name: LATASHA JARNAGIN
Title or Position: OWNER
Credential: FNP-BC
Phone: 865-898-8318