=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073014643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAST PACE MEDICAL CLINIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2018
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W BROAD ST
-----------------------------------------------------
City | SMITHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37166-1915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-632-3278
-----------------------------------------------------
Fax | 931-722-9919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1258
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38485-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-253-1110
-----------------------------------------------------
Fax | 931-722-9919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | ROBERT BENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-253-1110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------