=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235801176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA HISPANA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2021
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 WOLVERINE TRL STE 202
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37167-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-880-0593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 WOLVERINE TRL STE 202
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37167-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-880-0593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. TAMMY BRADLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-281-0553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------