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General NPI Number Information
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NPI Number | 1487656781
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Entity Type | Organization
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Legal Business Name | TOOELE CLINIC CORPORATION
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Dates
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Enumeration Date | 06/01/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 330 FRANKLIN RD #135A-304
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City | BRENTWOOD
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State | TN
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Zip | 37027-3280
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Country | US
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Telephone | 615-309-3338
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Fax |
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Provider Business Mailing Address
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Address Line | 330 FRANKLIN RD
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City | BRENTWOOD
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State | TN
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Zip | 37027-3280
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Country | US
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Telephone | 615-309-3338
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Fax |
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Authorized Official
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Title or Position | SENIOR GROUP VP
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Name | MR. MICHAELE PORTACCI
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Credential |
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Telephone | 615-309-3340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 87063588
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License Number State | UT
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