Healthcare Provider Details

I. General information

NPI: 1528361730
Provider Name (Legal Business Name): COVENANT FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHWAY 76
CLARKSVILLE TN
37043-8405
US

IV. Provider business mailing address

1000 HIGHWAY 76
CLARKSVILLE TN
37043-8405
US

V. Phone/Fax

Practice location:
  • Phone: 931-245-1150
  • Fax: 931-245-0605
Mailing address:
  • Phone: 931-245-1150
  • Fax: 931-245-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ROBERT ALAN WILSON
Title or Position: PRESIDENT
Credential: MD
Phone: 615-245-1150