Healthcare Provider Details

I. General information

NPI: 1013574664
Provider Name (Legal Business Name): CROCKETT HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 N MILITARY ST
LORETTO TN
38469-2336
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY ATTEN: PROVIDER ENROLLMENT
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 931-853-6970
  • Fax: 931-853-6974
Mailing address:
  • Phone: 615-920-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHY TEAGUE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7646