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General NPI Number Information
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NPI Number | 1689745069
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Entity Type | Organization
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Legal Business Name | FAMILY CARE CENTER LLC
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Dates
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Enumeration Date | 11/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 207 WEST LOCUST STREET
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City | LAFAYETTE
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State | TN
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Zip | 37083
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Country | US
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Telephone | 615-666-6425
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Fax | 615-666-3261
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Provider Business Mailing Address
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Address Line | 207 WEST LOCUST STREET
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City | LAFAYETTE
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State | TN
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Zip | 37083
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Country | US
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Telephone | 615-666-6425
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Fax | 615-666-3261
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Authorized Official
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Title or Position | OWNER
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Name | MR. HANNA C ILLA
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Credential | MD
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Telephone | 615-666-6425
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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 | MD30470
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License Number State | TN
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