Healthcare Provider Details

I. General information

NPI: 1790124097
Provider Name (Legal Business Name): THE GROVE PRIMARY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 S MAIN ST
MIDDLETON TN
38052-3615
US

IV. Provider business mailing address

702 S MAIN ST
MIDDLETON TN
38052-3615
US

V. Phone/Fax

Practice location:
  • Phone: 731-376-1311
  • Fax: 731-376-1314
Mailing address:
  • Phone: 731-376-1311
  • Fax: 731-376-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM J WYSOR
Title or Position: PRESIDENT
Credential:
Phone: 731-695-3537