Healthcare Provider Details

I. General information

NPI: 1285014241
Provider Name (Legal Business Name): THE GROVE PRIMARY CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9458 HIGHWAY 100
SCOTTS HILL TN
38374
US

IV. Provider business mailing address

9458 HIGHWAY 100
SCOTTS HILL TN
38374
US

V. Phone/Fax

Practice location:
  • Phone: 731-549-3010
  • Fax: 731-549-3013
Mailing address:
  • Phone:
  • Fax:

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: MR. WILLAM J WYSOR
Title or Position: PRESIDENT
Credential:
Phone: 731-983-0499