Healthcare Provider Details

I. General information

NPI: 1124215405
Provider Name (Legal Business Name): PROVIDENCE MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2354 HIGHWAY 41 S
GREENBRIER TN
37073-5510
US

IV. Provider business mailing address

172 FOXRUN
SPRINGFIELD TN
37172-7334
US

V. Phone/Fax

Practice location:
  • Phone: 615-483-6675
  • Fax:
Mailing address:
  • Phone: 615-483-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDY E FLORENDO
Title or Position: OWNER / PROVIDER
Credential: M.D.
Phone: 615-483-6675