=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831433283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCMINNVILLE PAIN RELIEF CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2012
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 SPARTA ST STE 4
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37110-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-474-1616
-----------------------------------------------------
Fax | 931-474-1618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 SPARTA ST STE 4
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37110-2698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-474-1616
-----------------------------------------------------
Fax | 931-474-1618
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MATT ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-474-1616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------