Basic Information
| Provider Information | |||||||||
| NPI: | 1558315689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRE CLINIC CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370245009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152211400 | ||||||||
| FaxNumber: | 6152211484 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 NORTHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | CENTRE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359601045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2569274900 | ||||||||
| FaxNumber: | 2569279151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | ARWOOD | ||||||||
| AuthorizedOfficialFirstName: | SOPHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR; AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6152211400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529928970 | 05 | AL | MEDICAID |