Healthcare Provider Details

I. General information

NPI: 1194023366
Provider Name (Legal Business Name): COMMUNITY QUICK CARE OF LAVERGNE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5148A MURFREESBORO RD
LA VERGNE TN
37086-2712
US

IV. Provider business mailing address

PO BOX 2684
BRENTWOOD TN
37024-2684
US

V. Phone/Fax

Practice location:
  • Phone: 615-213-1203
  • Fax: 615-527-0270
Mailing address:
  • Phone: 615-943-5072
  • Fax: 615-527-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number339630
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number339630
License Number StateTN

VIII. Authorized Official

Name: JERRY P. ELEDGE
Title or Position: CEO
Credential:
Phone: 615-943-5072