Basic Information
| Provider Information | |||||||||
| NPI: | 1265617674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTENNIAL PRIMARY CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 N LOCUST AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384642706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317620531 | ||||||||
| FaxNumber: | 9317620998 | ||||||||
| Practice Location | |||||||||
| Address1: | 1009 N LOCUST AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384642706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317620531 | ||||||||
| FaxNumber: | 9317620998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9547675716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL CORP. LLC | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 3370233 | 05 | TN | MEDICAID |