Healthcare Provider Details

I. General information

NPI: 1952355372
Provider Name (Legal Business Name): MAIN STREET FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MAIN ST
PORTLAND TN
37148-1218
US

IV. Provider business mailing address

120 MAIN ST
PORTLAND TN
37148-1218
US

V. Phone/Fax

Practice location:
  • Phone: 615-323-8873
  • Fax: 615-323-8874
Mailing address:
  • Phone: 615-323-8873
  • Fax: 615-323-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number33966
License Number StateTN

VIII. Authorized Official

Name: DR. STACEY D VANCE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 615-323-8873