Healthcare Provider Details

I. General information

NPI: 1457692667
Provider Name (Legal Business Name): FIRST CARE FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14821 DAYTON PIKE SUITE B
SALE CREEK TN
37373
US

IV. Provider business mailing address

14821 DAYTON PIKE, PO BOX 698 SUITE B
SALE CREEK TN
37373
US

V. Phone/Fax

Practice location:
  • Phone: 423-486-9455
  • Fax: 423-486-9458
Mailing address:
  • Phone: 423-486-9455
  • Fax: 423-486-9458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0000005828
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP16874
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number004944
License Number StateTN

VIII. Authorized Official

Name: JIM YOUNG
Title or Position: OWNER
Credential: APRN
Phone: 423-486-9455