Basic Information
| Provider Information | |||||||||
| NPI: | 1538703897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY MEDICAL CLINIC OF TREZEVANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 HURT ST | ||||||||
| Address2: | |||||||||
| City: | TREZEVANT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382582505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312070323 | ||||||||
| FaxNumber: | 7312408065 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 HURT ST | ||||||||
| Address2: | |||||||||
| City: | TREZEVANT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382582505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312070323 | ||||||||
| FaxNumber: | 7312408065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2019 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEGGETT | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7312003001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | Q054230 | 05 | TN | MEDICAID |