Healthcare Provider Details

I. General information

NPI: 1578819033
Provider Name (Legal Business Name): INGRAM CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

367 RIVERSIDE DR
FRANKLIN TN
37064-8984
US

IV. Provider business mailing address

367 RIVERSIDE DR
FRANKLIN TN
37064-8984
US

V. Phone/Fax

Practice location:
  • Phone: 615-946-2730
  • Fax:
Mailing address:
  • Phone: 615-946-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number31548
License Number StateTN

VIII. Authorized Official

Name: JACK BUCARAT
Title or Position: CEO
Credential:
Phone: 615-946-2730