Healthcare Provider Details

I. General information

NPI: 1013969179
Provider Name (Legal Business Name): COFFEE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 INTERSTATE DR
MANCHESTER TN
37355-3108
US

IV. Provider business mailing address

481 INTERSTATE DR
MANCHESTER TN
37355-3108
US

V. Phone/Fax

Practice location:
  • Phone: 931-728-3586
  • Fax:
Mailing address:
  • Phone: 931-728-6354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number0000000017
License Number StateTN

VIII. Authorized Official

Name: MS. MARTHA E MCCORMICK
Title or Position: CEO
Credential:
Phone: 931-728-6354