Basic Information
| Provider Information | |||||||||
| NPI: | 1619042470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WALLACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1404 WINTER DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370872530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157902900 | ||||||||
| FaxNumber: | 6155990718 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370405136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156736737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD 016624 | TN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 04720840061 | 01 | TN | ME # | OTHER |