Healthcare Provider Details

I. General information

NPI: 1770562142
Provider Name (Legal Business Name): TULLAHOMA PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CEDAR LN BLDG B SUITE 900
TULLAHOMA TN
37388-2283
US

IV. Provider business mailing address

PO BOX 1327
TULLAHOMA TN
37388-1327
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-2674
  • Fax: 931-455-7594
Mailing address:
  • Phone: 931-455-2674
  • Fax: 931-455-7594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROLINE B TUCK
Title or Position: ADMINISTRATOR
Credential:
Phone: 931-455-2674