=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518924760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLE FAMILY CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 MCARTHUR ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37355-2425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-728-6800
-----------------------------------------------------
Fax | 931-728-2911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1065
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37349-1065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-728-6800
-----------------------------------------------------
Fax | 931-728-2911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JOHN JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-728-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------