Healthcare Provider Details

I. General information

NPI: 1619199866
Provider Name (Legal Business Name): HUMBOLDT PRIMARY CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 HIGHWAY 51 S
COVINGTON TN
38019-3622
US

IV. Provider business mailing address

1830 HIGHWAY 51 SOUTH
COVINGTON TN
38019-0000
US

V. Phone/Fax

Practice location:
  • Phone: 901-475-1260
  • Fax: 901-475-1266
Mailing address:
  • Phone: 901-475-1260
  • Fax: 901-475-1266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMD29888
License Number StateTN

VIII. Authorized Official

Name: MRS. JAYASREE CHANDA
Title or Position: DOCTOR
Credential: MD
Phone: 901-475-1260