Healthcare Provider Details

I. General information

NPI: 1992162994
Provider Name (Legal Business Name): CAREHERE CLINIC-UTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 VIRGINIA WAY STE 350
BRENTWOOD TN
37027-2319
US

IV. Provider business mailing address

5141 VIRGINIA WAY STE 350
BRENTWOOD TN
37027-2319
US

V. Phone/Fax

Practice location:
  • Phone: 615-221-5901
  • Fax:
Mailing address:
  • Phone: 615-221-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8431757-1205
License Number StateUT

VIII. Authorized Official

Name: MR. ERNIE CLEVENGER
Title or Position: PRESIDENT
Credential:
Phone: 615-221-5901