Healthcare Provider Details

I. General information

NPI: 1942779509
Provider Name (Legal Business Name): WEST TENNESSEE PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 W PARK PL
HENDERSON TN
38340-2027
US

IV. Provider business mailing address

541 W PARK PL
HENDERSON TN
38340-2027
US

V. Phone/Fax

Practice location:
  • Phone: 731-989-1007
  • Fax: 731-989-0704
Mailing address:
  • Phone: 731-989-1007
  • Fax: 731-989-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAMERON BURKS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 731-608-0380