Basic Information
| Provider Information | |||||||||
| NPI: | 1558554386 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ON-SIGHT CONTINENCE CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7756 | ||||||||
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| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040756 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 131 N TUCKER ST | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017265600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2007 | ||||||||
| LastUpdateDate: | 02/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | SLACK | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2529851371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3370186 | 05 | TN | MEDICAID |