Healthcare Provider Details

I. General information

NPI: 1518106020
Provider Name (Legal Business Name): TIDWELL FAMILY VENTURES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S BROADWAY
PORTLAND TN
37148-1438
US

IV. Provider business mailing address

505 S BROADWAY
PORTLAND TN
37148-1438
US

V. Phone/Fax

Practice location:
  • Phone: 615-323-1020
  • Fax: 615-323-1021
Mailing address:
  • Phone: 615-323-1020
  • Fax: 615-323-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1755
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13982
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number10971
License Number StateTN

VIII. Authorized Official

Name: EMILY TIDWELL
Title or Position: MEMBER
Credential: NP
Phone: 615-323-1020