=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871587519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY HEALTHCARE OF MILLINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2005
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4772 NAVY RD
-----------------------------------------------------
City | MILLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38053-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-873-4501
-----------------------------------------------------
Fax | 901-873-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4772 NAVY RD
-----------------------------------------------------
City | MILLINGTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38053-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-873-4501
-----------------------------------------------------
Fax | 901-873-4505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER
-----------------------------------------------------
Name | REGINA S LINDSEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 901-873-4501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 18070
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------