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General NPI Number Information
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NPI Number | 1710351820
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Entity Type | Organization
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Legal Business Name | EAST FORK MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 11/30/2015
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Last Update Date | 11/30/2015
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Provider Practice Location Address
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Address Line | 370 DOOLITTLE RD #4
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City | WOODBURY
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State | TN
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Zip | 37190-1129
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Country | US
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Telephone | 615-855-7488
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Fax |
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Provider Business Mailing Address
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Address Line | 322 SAVANNAH RDG
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City | MURFREESBORO
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State | TN
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Zip | 37127-8349
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. JACK DEMPSEY HYDRICK II
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Credential | NP
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Telephone | 615-855-7488
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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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