Basic Information
| Provider Information | |||||||||
| NPI: | 1225072473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND PRIMARY CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 REDBUD DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153251206 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 REDBUD DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORTLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371481617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153251206 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6153251206 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.