Healthcare Provider Details

I. General information

NPI: 1275873424
Provider Name (Legal Business Name): LAKE COUNTY PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 CARL PERKINS PKWY
TIPTONVILLE TN
38079-1678
US

IV. Provider business mailing address

710 CARL PERKINS PKWY
TIPTONVILLE TN
38079-1678
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-6690
  • Fax: 731-253-6692
Mailing address:
  • Phone: 731-253-6690
  • Fax: 731-253-6692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number17394
License Number StateTN

VIII. Authorized Official

Name: DR. CAROL WINFRED GUESS
Title or Position: MEDICAL DIRECTOR
Credential: MEDICAL DOCTOR
Phone: 731-253-6690