Healthcare Provider Details

I. General information

NPI: 1407076060
Provider Name (Legal Business Name): PRIMECARE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHICKADEE AVE
MIDDLETON TN
38052-3425
US

IV. Provider business mailing address

PO BOX 479
BOLIVAR TN
38008-0479
US

V. Phone/Fax

Practice location:
  • Phone: 731-376-0034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25889
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38934
License Number StateTN

VIII. Authorized Official

Name: BARBARA NKOMAZANA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 731-376-1851