Healthcare Provider Details

I. General information

NPI: 1689843153
Provider Name (Legal Business Name): AMG-CROCKETT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 PROSSER RD
LAWRENCEBURG TN
38464-4233
US

IV. Provider business mailing address

PO BOX 847 US HIGHWAY 43 SOUTH
LAWRENCEBURG TN
38464-0847
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-1800
  • Fax: 931-762-9155
Mailing address:
  • Phone: 931-762-6571
  • Fax: 931-766-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JONE LAW KOFORD
Title or Position: DIVISION PRESIDENT
Credential:
Phone: 615-372-8503