Basic Information
| Provider Information | |||||||||
| NPI: | 1437614633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINELAKE PHYSICIAN PRACTICE LLC | ||||||||
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| OtherOrganizationName: | JACKSON PURCHASE PRIMARY CARE - CLINTON CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207192 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 W CLAY ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420311317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706530220 | ||||||||
| FaxNumber: | 2706530221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEBLEU | ||||||||
| AuthorizedOfficialFirstName: | SHARLEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR DIRECTOR, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207VX0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.