Healthcare Provider Details

I. General information

NPI: 1265099634
Provider Name (Legal Business Name): GERIATRIC CLINICAL CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5606 CLOVERLAND DR APT 110
BRENTWOOD TN
37027-4877
US

IV. Provider business mailing address

4849 N MESA ST STE 201
EL PASO TX
79912-5919
US

V. Phone/Fax

Practice location:
  • Phone: 615-200-0981
  • Fax:
Mailing address:
  • Phone: 915-351-6600
  • Fax: 915-351-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIFFANY PEGGS
Title or Position: OWNER
Credential: MD
Phone: 901-831-6844