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General NPI Number Information
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NPI Number | 1487476636
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Entity Type | Organization
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Legal Business Name | LIFE COORDINATED COMMONWEALTH PACE INC
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Dates
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Enumeration Date | 10/29/2024
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 201 E 11TH ST
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City | BENTON
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State | KY
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Zip | 42025-1515
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Country | US
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Telephone | 855-209-5451
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2403
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City | BRENTWOOD
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State | TN
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Zip | 37024-2403
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Country | US
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Telephone | 615-376-4677
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | NANCY C EVERITT
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Credential | PMP
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Telephone | 615-376-4677
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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