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NPI Code Detail

MEDICARE: THE GROVE PRIMARY CARE CLINIC LLC

MEDICARE: THE GROVE PRIMARY CARE CLINIC 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
1261QR1300XRural Health Clinic/Center

General Provider Information

NPI Number : 1639345952
Entity Type Code : Organization
Provider Name (Legal Business Name) : THE GROVE PRIMARY CARE CLINIC LLC
Provider Business Mailing Address
First Line : 541 W PARK PL
Second Line : SUITE C
City : HENDERSON
State : TN
Zip : 38340-2027
Country : US
Telephone Number : 731-983-0499
Fax Number : 731-983-0573
Provider Business Practice Location Address
First Line : 541 W PARK PL
Second Line : SUITE C
City : HENDERSON
State : TN
Zip : 38340-2027
Country : US
Telephone Number : 731-983-0499
Fax Number : 731-983-0573
Authorized Official
Title or Position : OWNER
Name : JODY WYSOR
Credential :
Telephone Number : 731-983-0499
Provider Enumeration Date : 05/06/2008
Last Update Date : 09/10/2019

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Directions to “THE GROVE PRIMARY CARE CLINIC LLC ” Practice Location

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