=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154666451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE VACCINATION CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2012
-----------------------------------------------------
Last Update Date | 11/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7648 HIGHWAY 70 S SUITE 15
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37221-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-469-7413
-----------------------------------------------------
Fax | 615-469-5935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7648 HIGHWAY 70 S SUITE 15
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37221-1742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-469-7413
-----------------------------------------------------
Fax | 615-469-5935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MRS. KAYE J IVANOFF
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 615-525-7618
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------