Healthcare Provider Details

I. General information

NPI: 1164069084
Provider Name (Legal Business Name): PREMIER CARE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 OUTDOOR SPORTSMAN PL STE 7
KODAK TN
37764-1477
US

IV. Provider business mailing address

3609 OUTDOOR SPORTSMAN PL STE 7
KODAK TN
37764-1477
US

V. Phone/Fax

Practice location:
  • Phone: 865-210-3452
  • Fax:
Mailing address:
  • Phone: 865-210-3452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. IAN P CLARKE
Title or Position: OWNER
Credential:
Phone: 865-281-5922