MEDICARE: PORTLAND PRIMARY CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1225072473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND PRIMARY CARE, LLC

Provider Business Mailing Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE E
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-1206
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE E
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-1206
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	CHUCK LOCKE
Credential	:
Telephone Number	:	615-325-1206

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	08/22/2020

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Directions to “PORTLAND PRIMARY CARE, LLC ” Practice Location

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